Career

I have had the pleasure of working on the Society of Hospital Medicine’s signature Leadership Academies since 2010, and I enjoy working with hospital medicine leaders from around the country every year. I started as a hospital medicine leader in 2000 and served during the unprecedented growth of the field when it was “the most rapidly growing specialty in the history of medicine.”

Most businesses dream of having a year of double-digit growth; my department grew an average of 15% annually for more than 10 years. These unique experiences have taught me many lessons and afforded me the opportunity to watch many stars of hospital medicine rise, as well as to learn from several less-scrupulous leaders about the darker side of hospital politics.

One of the lessons I learned the hard way about hospital politics is striking the “Authority/Accountability balance” in your career. I shared this perspective at the SHM annual conference in 2018, at speaking engagements on the West Coast, and with my leadership group at the academies. I am sharing it with you because the feedback I have received has been very positive.

The Authority/Accountability balance is a tool for evaluating your current career trajectory and measuring if it is set up for success or failure. The essence is that your Authority and Accountability need to be balanced for you to be successful in your career, regardless of your station. Everybody from the hospitalist fresh out of residency to the CEO needs to have Authority and Accountability in balance to be successful. And as you use the tool to measure your own potential for success or failure, learn to apply it to those who report to you.

I believe the rising tide lifts all boats and the success of your subordinates, through mentoring and support, will add to your success. There is another, more cynical view of subordinates that can be identified using the Authority/Accountability balance, which I will address.
 

Authority

In this construct, “Authority” has a much broader meaning than just the ability to tell people what to do. The ability to tell people what to do is important but not sufficient for success in hospital politics.

Financial resources are essential for a successful Authority/Accountability balance – not only the hardware such as computers, telephones, pagers, and so on, but also clerical support, technical support, and analytic support so that you are getting high-quality data on the performance of the members of your hospital medicine group (HMG). These “soft” resources (clerical, technical, and analytical) are often overlooked as needs that HMG leaders must advocate for; I speak with many HMG leaders who remain under-resourced with “soft” assets. However, being appropriately resourced in these areas can be transformational for a group. Hospitalists don’t like doing clerical work, and if you don’t like a menial job assigned to you, you probably won’t do it very well. Having an unlicensed person dedicated to these clerical activities not only will cost less, but will ensure the job is done better.

Reporting structure is critically important, often overlooked, and historically misaligned in HMGs. When hospital medicine was starting in the late 1990s and early 2000s, rapidly growing hospitalist groups were typically led by young, early-career physicians who had chosen hospital medicine as a career. The problem was that they often lacked the seniority and connections at the executive level to advocate for their HMG. All too often the hospitalist group was tucked in under another department or division which, in turn, reported HMG updates and issues to the board of directors and the CEO.

A common reporting structure in the early days was that a senior member of the medical staff, or group, had once worked in the hospital and therefore “understood” the issues and challenges that the hospitalists were facing. It was up to this physician with seniority and connections to advocate for the hospitalists as they saw fit. The problem was that the hospital landscape was, and is, constantly evolving in innumerable ways. These “once removed” reporting structures for HMGs failed to get the required information on the rapidly changing, and evolving, hospitalist landscape to the desks of executives who had the financial and structural control to address the challenges that the hospitalists in the trenches were facing.

Numerous HMGs failed in the early days of hospital medicine because of this type of misaligned reporting structure. This is a lesson that should not be forgotten: Make sure your HMG leader has a seat at the table where executive decisions are made, including but not limited to the board of directors. To be in balance, you have to be “in the room where it happens.”
 

Accountability

The outcomes that you are responsible for need to be explicit, appropriately resourced with Authority, and clearly spelled out in your job description. Your job description is a document you should know, own, and revisit regularly with whomever you report to, in order to ensure success.

Once you have the Authority side of the equation appropriately resourced, setting outcomes that are a stretch, but still realistic and achievable within the scope of your position, is critical to your success. It is good to think about short-, medium-, and long-term goals, especially if you are in a leadership role. For example, one expectation you will have, regardless of your station, is that you keep up on your email and answer your phone. These are short-term goals that will often be included in your job description. However, taking on a new hospital contract and making sure that it has 24/7 hospitalist coverage, that all the hospitalists are meeting the geometric mean length of stay, and that all the physicians are having 15 encounters per day doesn’t happen immediately. Long-term goals, such as taking on a new hospital contract, are the big-picture stuff that can make or break the career of an HMG leader. Long-term goals also need to be delineated in the job description, along with specific time stamps and the resources you need to accomplish big ticket items – which are spelled out in the Authority side (that is, physician recruiter, secretary, background checks, and so on).

One of the classic misuses of Accountability is the “Fall Guy” scenario. The Fall Guy scenario is often used by cynical hospital and medical group executives to expand their influence while limiting their liability. In the Fall Guy scenario, the executive is surrounded with junior partners who are underpowered with Authority, and then the executive makes decisions for which the junior partners are Accountable. This allows the senior executive to make risky decisions on behalf of the hospital or medical group without the liability of being held accountable when the decision-making process fails. When the risky, and often ill-informed, decision fails, the junior partner who lacked the Authority to make the decision – but held the Accountability for it – becomes the Fall Guy for the failed endeavor. This is a critical outcome that the Authority/Accountability balance can help you avoid, if you use it wisely and properly.

If you find yourself in the Fall Guy position, it is time for a change. The Authority, the Accountability, or both need to change so that they are in better balance. Or your employer needs to change. Changing employers is an outcome worth avoiding, if at all possible. I have scrutinized thousands of resumes in my career, and frequent job changes always wave a red flag to prospective employers. However, changing jobs remains a crucial option if you are being set up for failure when Authority and Accountability are out of balance.

If you are unable to negotiate for the balance that will allow you to be successful with your current group, remember that HMG leaders are a prized commodity and in short supply. Leaving a group that has been your career is hard, but it is better to leave than stay in a position where you are set up for failure as the Fall Guy. Further, the most effective time to expand your Authority is when you are negotiating the terms of a new position. Changing positions is the nuclear option. However, it is better than becoming the Fall Guy, and a change can create opportunities that will accelerate your career and influence, if done right.

When I talk about Authority/Accountability balance, I always counter the Fall Guy with an ignominious historical figure: General George B. McClellan. General McClellan was the commander of the Army of the Potomac during the early years of the American Civil War. General McClellan had the industrial might of the Union north at his beck and call, as well as extraordinary resources for recruiting and retaining soldiers for his army. At every encounter with General Robert E. Lee’s Army of Northern Virginia, General McClellan outnumbered them, sometimes by more than two to one. Yet General McClellan was outfoxed repeatedly for the same reason: He failed to take decisive action.

Every time that McClellan failed, he blamed insufficient resources and told President Lincoln that he needed more troops and more equipment to be successful. In summary, while the Fall Guy scenario needs to be avoided, once you are adequately resourced, success requires taking decisive and strategic action, or you will suffer as did General McClellan. Failing to act when you are appropriately resourced can be just as damaging to your career and credibility as allowing yourself to become the Fall Guy.
 

Job description

Everybody has somebody that they report to, no matter how high up on the executive ladder they have climbed. Even the CEO must report to the board of directors. And that reporting structure usually involves periodic formal reviews. Your formal review is a good time to go over your job description, note what is relevant, remove what is irrelevant, and add new elements that have evolved in importance since your last review.

Job descriptions take many forms, but they always include a list of qualifications. If you have the job, you have the qualifications, so that is not likely to change. You may become more qualified for a higher-level position, but that is an entirely different discussion. I like to think of a well-written job description as including short-term and long-term goals. Short-term goals are usually the daily stuff that keeps operations running smoothly but garners little attention. Examples would include staying current on your emails, answering your phone, organizing meetings, and regularly attending various committees. Even some of these short-term goals can and will change over time. I always enjoyed quality oversight in my department, but as the department and my responsibilities grew, I realized I couldn’t do everything that I wanted to do. I needed to focus on the things only I could do and delegate those things that could be done by someone else, even though I wanted to continue doing them myself. I created a position for a clinical quality officer, and quality oversight moved off of my job description.

Long-term goals are the aspirational items, such as increasing market share, decreasing readmissions, improving patient satisfaction, and the like. Effective leaders are often focused on these aspirational, long-term goals, but they still must effectively execute their short-term goals. Stephen Covey outlines the dilemma with the “time management matrix” in his seminal work “The 7 Habits of Highly Effective People.” An in-depth discussion is beyond the scope of this article, but the time management matrix places tasks into one of four categories based on urgency and importance, and provides strategies for staying up on short-term goals while continually moving long-term goals forward.If you show up at your review with a list of accomplishments as well as an understanding of how the “time management matrix” affects your responsibilities, your boss will be impressed. It is also worth mentioning that Covey’s first habit is “Proactivity.” He uses the term Proactivity in a much more nuanced form than we typically think of, however. Simply put, Proactivity is the opposite of Reactivity, and it is another invaluable tool for success with those long-term goals that will help you make a name for yourself.

When you show up for your review, be it annual, biannual, or other, be prepared. Not only should you bring your job description and recommendations for how it should be adapted in the changing environment, but also bring examples of your accomplishments since the last review.

I talk with leaders frequently who are hardworking and diligent and hate bragging about their achievements; I get that. At the same time, if you don’t inform your superiors about your successes, there is no guarantee that they will hear about them or understand them in the appropriate context. Bragging about how great you are in the physician’s lounge is annoying; telling your boss about your accomplishments since the last review is critical to maintaining the momentum of past accomplishments. If you are not willing to toot your own horn, there is a very good chance that your horn will remain silent. I don’t think self-promotion comes easily to anyone, and it has to be done with a degree of humility and sensitivity; but it has to be done, so prepare for it.
 

Look out for yourself and others

We talk about teamwork and collaboration as hospitalists, and SHM is always underscoring the importance of teamwork and highlighting examples of successful teamwork in its many conferences and publications. Most hospital executives are focused on their own careers, however, and many have no reservations about damaging your career (your brand) if they think it will promote theirs. You have to look out for yourself and size up every leadership position you get into.

Physicians can expect their careers to last decades. The average hospital CEO has a tenure of less than 3.5 years, however, and when a new CEO is hired, almost half of chief financial, chief operating, and chief information officers are fired within 9 months. You may be focused on the long-term success of your organization as you plan your career, but many hospital administrators are interested only in short-term gains. It is similar to some members of Congress who are interested only in what they need to do now to win the next election and not in the long-term needs of the country. You should understand this disconnect when dealing with hospital executives, and how you and your credibility can become cannon fodder in their quest for short-term self-preservation.

You have to look out for and take care of yourself as you promote your group. With a better understanding of the Authority/Accountability balance, you have new tools to assess your chances of success and to advocate for yourself so that you and your group can be successful.

Despite my cynicism toward executives in the medical field, I personally advocate for supporting the career development of those around you and advise against furthering your career at the expense of others. Many unscrupulous executives will use this approach, surrounding themselves with Fall Guys, but my experience shows that this is not a sustainable strategy for success. It can lead to short-term gains, but eventually the piper must be paid. Moreover, the most successful medical executives and leaders that I have encountered have been those who genuinely cared about their subordinates, looked out for them, and selflessly promoted their careers.

In the age of social media, tearing others down seems to be the fastest way to get more “likes.” However, I strongly believe that you can’t build up your group, and our profession, just by tearing people down. Lending a helping hand may bring you less attention in the short term, but such action raises your stature, creates loyalty, and leads to sustainable success for the long run.
 

Dr. McIlraith is the founding chairman of the Hospital Medicine Department at Mercy Medical Group in Sacramento, Calif. He received the SHM Award for Outstanding Service in Hospital Medicine in 2016 and is currently a member of the SHM Practice Management and Awards Committees, as well as the SHM Critical Care Task Force.

Sources

Quinn R. HM Turns 20: A look at the evolution of hospital medicine. The Hospitalist. 2016 August. https://www.the-hospitalist.org/hospitalist/article/121525/hm-turns-20-look-evolution-hospital-medicine

Stephen R. Covey. The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. Simon & Schuster. 1989.

10 Statistics on CEO Turnover, Recruitment. Becker’s Hospital Review. 2020. https://www.beckershospitalreview.com/hospital-management-administration/10-statistics-on-ceo-turnover-recruitment.html

I have had the pleasure of working on the Society of Hospital Medicine’s signature Leadership Academies since 2010, and I enjoy working with hospital medicine leaders from around the country every year. I started as a hospital medicine leader in 2000 and served during the unprecedented growth of the field when it was “the most rapidly growing specialty in the history of medicine.”

Most businesses dream of having a year of double-digit growth; my department grew an average of 15% annually for more than 10 years. These unique experiences have taught me many lessons and afforded me the opportunity to watch many stars of hospital medicine rise, as well as to learn from several less-scrupulous leaders about the darker side of hospital politics.

One of the lessons I learned the hard way about hospital politics is striking the “Authority/Accountability balance” in your career. I shared this perspective at the SHM annual conference in 2018, at speaking engagements on the West Coast, and with my leadership group at the academies. I am sharing it with you because the feedback I have received has been very positive.

The Authority/Accountability balance is a tool for evaluating your current career trajectory and measuring if it is set up for success or failure. The essence is that your Authority and Accountability need to be balanced for you to be successful in your career, regardless of your station. Everybody from the hospitalist fresh out of residency to the CEO needs to have Authority and Accountability in balance to be successful. And as you use the tool to measure your own potential for success or failure, learn to apply it to those who report to you.

I believe the rising tide lifts all boats and the success of your subordinates, through mentoring and support, will add to your success. There is another, more cynical view of subordinates that can be identified using the Authority/Accountability balance, which I will address.
 

Authority

In this construct, “Authority” has a much broader meaning than just the ability to tell people what to do. The ability to tell people what to do is important but not sufficient for success in hospital politics.

Financial resources are essential for a successful Authority/Accountability balance – not only the hardware such as computers, telephones, pagers, and so on, but also clerical support, technical support, and analytic support so that you are getting high-quality data on the performance of the members of your hospital medicine group (HMG). These “soft” resources (clerical, technical, and analytical) are often overlooked as needs that HMG leaders must advocate for; I speak with many HMG leaders who remain under-resourced with “soft” assets. However, being appropriately resourced in these areas can be transformational for a group. Hospitalists don’t like doing clerical work, and if you don’t like a menial job assigned to you, you probably won’t do it very well. Having an unlicensed person dedicated to these clerical activities not only will cost less, but will ensure the job is done better.

Reporting structure is critically important, often overlooked, and historically misaligned in HMGs. When hospital medicine was starting in the late 1990s and early 2000s, rapidly growing hospitalist groups were typically led by young, early-career physicians who had chosen hospital medicine as a career. The problem was that they often lacked the seniority and connections at the executive level to advocate for their HMG. All too often the hospitalist group was tucked in under another department or division which, in turn, reported HMG updates and issues to the board of directors and the CEO.

A common reporting structure in the early days was that a senior member of the medical staff, or group, had once worked in the hospital and therefore “understood” the issues and challenges that the hospitalists were facing. It was up to this physician with seniority and connections to advocate for the hospitalists as they saw fit. The problem was that the hospital landscape was, and is, constantly evolving in innumerable ways. These “once removed” reporting structures for HMGs failed to get the required information on the rapidly changing, and evolving, hospitalist landscape to the desks of executives who had the financial and structural control to address the challenges that the hospitalists in the trenches were facing.

Numerous HMGs failed in the early days of hospital medicine because of this type of misaligned reporting structure. This is a lesson that should not be forgotten: Make sure your HMG leader has a seat at the table where executive decisions are made, including but not limited to the board of directors. To be in balance, you have to be “in the room where it happens.”
 

Accountability

The outcomes that you are responsible for need to be explicit, appropriately resourced with Authority, and clearly spelled out in your job description. Your job description is a document you should know, own, and revisit regularly with whomever you report to, in order to ensure success.

Once you have the Authority side of the equation appropriately resourced, setting outcomes that are a stretch, but still realistic and achievable within the scope of your position, is critical to your success. It is good to think about short-, medium-, and long-term goals, especially if you are in a leadership role. For example, one expectation you will have, regardless of your station, is that you keep up on your email and answer your phone. These are short-term goals that will often be included in your job description. However, taking on a new hospital contract and making sure that it has 24/7 hospitalist coverage, that all the hospitalists are meeting the geometric mean length of stay, and that all the physicians are having 15 encounters per day doesn’t happen immediately. Long-term goals, such as taking on a new hospital contract, are the big-picture stuff that can make or break the career of an HMG leader. Long-term goals also need to be delineated in the job description, along with specific time stamps and the resources you need to accomplish big ticket items – which are spelled out in the Authority side (that is, physician recruiter, secretary, background checks, and so on).

One of the classic misuses of Accountability is the “Fall Guy” scenario. The Fall Guy scenario is often used by cynical hospital and medical group executives to expand their influence while limiting their liability. In the Fall Guy scenario, the executive is surrounded with junior partners who are underpowered with Authority, and then the executive makes decisions for which the junior partners are Accountable. This allows the senior executive to make risky decisions on behalf of the hospital or medical group without the liability of being held accountable when the decision-making process fails. When the risky, and often ill-informed, decision fails, the junior partner who lacked the Authority to make the decision – but held the Accountability for it – becomes the Fall Guy for the failed endeavor. This is a critical outcome that the Authority/Accountability balance can help you avoid, if you use it wisely and properly.

If you find yourself in the Fall Guy position, it is time for a change. The Authority, the Accountability, or both need to change so that they are in better balance. Or your employer needs to change. Changing employers is an outcome worth avoiding, if at all possible. I have scrutinized thousands of resumes in my career, and frequent job changes always wave a red flag to prospective employers. However, changing jobs remains a crucial option if you are being set up for failure when Authority and Accountability are out of balance.

If you are unable to negotiate for the balance that will allow you to be successful with your current group, remember that HMG leaders are a prized commodity and in short supply. Leaving a group that has been your career is hard, but it is better to leave than stay in a position where you are set up for failure as the Fall Guy. Further, the most effective time to expand your Authority is when you are negotiating the terms of a new position. Changing positions is the nuclear option. However, it is better than becoming the Fall Guy, and a change can create opportunities that will accelerate your career and influence, if done right.

When I talk about Authority/Accountability balance, I always counter the Fall Guy with an ignominious historical figure: General George B. McClellan. General McClellan was the commander of the Army of the Potomac during the early years of the American Civil War. General McClellan had the industrial might of the Union north at his beck and call, as well as extraordinary resources for recruiting and retaining soldiers for his army. At every encounter with General Robert E. Lee’s Army of Northern Virginia, General McClellan outnumbered them, sometimes by more than two to one. Yet General McClellan was outfoxed repeatedly for the same reason: He failed to take decisive action.

Every time that McClellan failed, he blamed insufficient resources and told President Lincoln that he needed more troops and more equipment to be successful. In summary, while the Fall Guy scenario needs to be avoided, once you are adequately resourced, success requires taking decisive and strategic action, or you will suffer as did General McClellan. Failing to act when you are appropriately resourced can be just as damaging to your career and credibility as allowing yourself to become the Fall Guy.
 

Job description

Everybody has somebody that they report to, no matter how high up on the executive ladder they have climbed. Even the CEO must report to the board of directors. And that reporting structure usually involves periodic formal reviews. Your formal review is a good time to go over your job description, note what is relevant, remove what is irrelevant, and add new elements that have evolved in importance since your last review.

Job descriptions take many forms, but they always include a list of qualifications. If you have the job, you have the qualifications, so that is not likely to change. You may become more qualified for a higher-level position, but that is an entirely different discussion. I like to think of a well-written job description as including short-term and long-term goals. Short-term goals are usually the daily stuff that keeps operations running smoothly but garners little attention. Examples would include staying current on your emails, answering your phone, organizing meetings, and regularly attending various committees. Even some of these short-term goals can and will change over time. I always enjoyed quality oversight in my department, but as the department and my responsibilities grew, I realized I couldn’t do everything that I wanted to do. I needed to focus on the things only I could do and delegate those things that could be done by someone else, even though I wanted to continue doing them myself. I created a position for a clinical quality officer, and quality oversight moved off of my job description.

Long-term goals are the aspirational items, such as increasing market share, decreasing readmissions, improving patient satisfaction, and the like. Effective leaders are often focused on these aspirational, long-term goals, but they still must effectively execute their short-term goals. Stephen Covey outlines the dilemma with the “time management matrix” in his seminal work “The 7 Habits of Highly Effective People.” An in-depth discussion is beyond the scope of this article, but the time management matrix places tasks into one of four categories based on urgency and importance, and provides strategies for staying up on short-term goals while continually moving long-term goals forward.If you show up at your review with a list of accomplishments as well as an understanding of how the “time management matrix” affects your responsibilities, your boss will be impressed. It is also worth mentioning that Covey’s first habit is “Proactivity.” He uses the term Proactivity in a much more nuanced form than we typically think of, however. Simply put, Proactivity is the opposite of Reactivity, and it is another invaluable tool for success with those long-term goals that will help you make a name for yourself.

When you show up for your review, be it annual, biannual, or other, be prepared. Not only should you bring your job description and recommendations for how it should be adapted in the changing environment, but also bring examples of your accomplishments since the last review.

I talk with leaders frequently who are hardworking and diligent and hate bragging about their achievements; I get that. At the same time, if you don’t inform your superiors about your successes, there is no guarantee that they will hear about them or understand them in the appropriate context. Bragging about how great you are in the physician’s lounge is annoying; telling your boss about your accomplishments since the last review is critical to maintaining the momentum of past accomplishments. If you are not willing to toot your own horn, there is a very good chance that your horn will remain silent. I don’t think self-promotion comes easily to anyone, and it has to be done with a degree of humility and sensitivity; but it has to be done, so prepare for it.
 

Look out for yourself and others

We talk about teamwork and collaboration as hospitalists, and SHM is always underscoring the importance of teamwork and highlighting examples of successful teamwork in its many conferences and publications. Most hospital executives are focused on their own careers, however, and many have no reservations about damaging your career (your brand) if they think it will promote theirs. You have to look out for yourself and size up every leadership position you get into.

Physicians can expect their careers to last decades. The average hospital CEO has a tenure of less than 3.5 years, however, and when a new CEO is hired, almost half of chief financial, chief operating, and chief information officers are fired within 9 months. You may be focused on the long-term success of your organization as you plan your career, but many hospital administrators are interested only in short-term gains. It is similar to some members of Congress who are interested only in what they need to do now to win the next election and not in the long-term needs of the country. You should understand this disconnect when dealing with hospital executives, and how you and your credibility can become cannon fodder in their quest for short-term self-preservation.

You have to look out for and take care of yourself as you promote your group. With a better understanding of the Authority/Accountability balance, you have new tools to assess your chances of success and to advocate for yourself so that you and your group can be successful.

Despite my cynicism toward executives in the medical field, I personally advocate for supporting the career development of those around you and advise against furthering your career at the expense of others. Many unscrupulous executives will use this approach, surrounding themselves with Fall Guys, but my experience shows that this is not a sustainable strategy for success. It can lead to short-term gains, but eventually the piper must be paid. Moreover, the most successful medical executives and leaders that I have encountered have been those who genuinely cared about their subordinates, looked out for them, and selflessly promoted their careers.

In the age of social media, tearing others down seems to be the fastest way to get more “likes.” However, I strongly believe that you can’t build up your group, and our profession, just by tearing people down. Lending a helping hand may bring you less attention in the short term, but such action raises your stature, creates loyalty, and leads to sustainable success for the long run.
 

Dr. McIlraith is the founding chairman of the Hospital Medicine Department at Mercy Medical Group in Sacramento, Calif. He received the SHM Award for Outstanding Service in Hospital Medicine in 2016 and is currently a member of the SHM Practice Management and Awards Committees, as well as the SHM Critical Care Task Force.

Sources

Quinn R. HM Turns 20: A look at the evolution of hospital medicine. The Hospitalist. 2016 August. https://www.the-hospitalist.org/hospitalist/article/121525/hm-turns-20-look-evolution-hospital-medicine

Stephen R. Covey. The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. Simon & Schuster. 1989.

10 Statistics on CEO Turnover, Recruitment. Becker’s Hospital Review. 2020. https://www.beckershospitalreview.com/hospital-management-administration/10-statistics-on-ceo-turnover-recruitment.html

I have had the pleasure of working on the Society of Hospital Medicine’s signature Leadership Academies since 2010, and I enjoy working with hospital medicine leaders from around the country every year. I started as a hospital medicine leader in 2000 and served during the unprecedented growth of the field when it was “the most rapidly growing specialty in the history of medicine.”

Most businesses dream of having a year of double-digit growth; my department grew an average of 15% annually for more than 10 years. These unique experiences have taught me many lessons and afforded me the opportunity to watch many stars of hospital medicine rise, as well as to learn from several less-scrupulous leaders about the darker side of hospital politics.

One of the lessons I learned the hard way about hospital politics is striking the “Authority/Accountability balance” in your career. I shared this perspective at the SHM annual conference in 2018, at speaking engagements on the West Coast, and with my leadership group at the academies. I am sharing it with you because the feedback I have received has been very positive.

The Authority/Accountability balance is a tool for evaluating your current career trajectory and measuring if it is set up for success or failure. The essence is that your Authority and Accountability need to be balanced for you to be successful in your career, regardless of your station. Everybody from the hospitalist fresh out of residency to the CEO needs to have Authority and Accountability in balance to be successful. And as you use the tool to measure your own potential for success or failure, learn to apply it to those who report to you.

I believe the rising tide lifts all boats and the success of your subordinates, through mentoring and support, will add to your success. There is another, more cynical view of subordinates that can be identified using the Authority/Accountability balance, which I will address.
 

Authority

In this construct, “Authority” has a much broader meaning than just the ability to tell people what to do. The ability to tell people what to do is important but not sufficient for success in hospital politics.

Financial resources are essential for a successful Authority/Accountability balance – not only the hardware such as computers, telephones, pagers, and so on, but also clerical support, technical support, and analytic support so that you are getting high-quality data on the performance of the members of your hospital medicine group (HMG). These “soft” resources (clerical, technical, and analytical) are often overlooked as needs that HMG leaders must advocate for; I speak with many HMG leaders who remain under-resourced with “soft” assets. However, being appropriately resourced in these areas can be transformational for a group. Hospitalists don’t like doing clerical work, and if you don’t like a menial job assigned to you, you probably won’t do it very well. Having an unlicensed person dedicated to these clerical activities not only will cost less, but will ensure the job is done better.

Reporting structure is critically important, often overlooked, and historically misaligned in HMGs. When hospital medicine was starting in the late 1990s and early 2000s, rapidly growing hospitalist groups were typically led by young, early-career physicians who had chosen hospital medicine as a career. The problem was that they often lacked the seniority and connections at the executive level to advocate for their HMG. All too often the hospitalist group was tucked in under another department or division which, in turn, reported HMG updates and issues to the board of directors and the CEO.

A common reporting structure in the early days was that a senior member of the medical staff, or group, had once worked in the hospital and therefore “understood” the issues and challenges that the hospitalists were facing. It was up to this physician with seniority and connections to advocate for the hospitalists as they saw fit. The problem was that the hospital landscape was, and is, constantly evolving in innumerable ways. These “once removed” reporting structures for HMGs failed to get the required information on the rapidly changing, and evolving, hospitalist landscape to the desks of executives who had the financial and structural control to address the challenges that the hospitalists in the trenches were facing.

Numerous HMGs failed in the early days of hospital medicine because of this type of misaligned reporting structure. This is a lesson that should not be forgotten: Make sure your HMG leader has a seat at the table where executive decisions are made, including but not limited to the board of directors. To be in balance, you have to be “in the room where it happens.”
 

Accountability

The outcomes that you are responsible for need to be explicit, appropriately resourced with Authority, and clearly spelled out in your job description. Your job description is a document you should know, own, and revisit regularly with whomever you report to, in order to ensure success.

Once you have the Authority side of the equation appropriately resourced, setting outcomes that are a stretch, but still realistic and achievable within the scope of your position, is critical to your success. It is good to think about short-, medium-, and long-term goals, especially if you are in a leadership role. For example, one expectation you will have, regardless of your station, is that you keep up on your email and answer your phone. These are short-term goals that will often be included in your job description. However, taking on a new hospital contract and making sure that it has 24/7 hospitalist coverage, that all the hospitalists are meeting the geometric mean length of stay, and that all the physicians are having 15 encounters per day doesn’t happen immediately. Long-term goals, such as taking on a new hospital contract, are the big-picture stuff that can make or break the career of an HMG leader. Long-term goals also need to be delineated in the job description, along with specific time stamps and the resources you need to accomplish big ticket items – which are spelled out in the Authority side (that is, physician recruiter, secretary, background checks, and so on).

One of the classic misuses of Accountability is the “Fall Guy” scenario. The Fall Guy scenario is often used by cynical hospital and medical group executives to expand their influence while limiting their liability. In the Fall Guy scenario, the executive is surrounded with junior partners who are underpowered with Authority, and then the executive makes decisions for which the junior partners are Accountable. This allows the senior executive to make risky decisions on behalf of the hospital or medical group without the liability of being held accountable when the decision-making process fails. When the risky, and often ill-informed, decision fails, the junior partner who lacked the Authority to make the decision – but held the Accountability for it – becomes the Fall Guy for the failed endeavor. This is a critical outcome that the Authority/Accountability balance can help you avoid, if you use it wisely and properly.

If you find yourself in the Fall Guy position, it is time for a change. The Authority, the Accountability, or both need to change so that they are in better balance. Or your employer needs to change. Changing employers is an outcome worth avoiding, if at all possible. I have scrutinized thousands of resumes in my career, and frequent job changes always wave a red flag to prospective employers. However, changing jobs remains a crucial option if you are being set up for failure when Authority and Accountability are out of balance.

If you are unable to negotiate for the balance that will allow you to be successful with your current group, remember that HMG leaders are a prized commodity and in short supply. Leaving a group that has been your career is hard, but it is better to leave than stay in a position where you are set up for failure as the Fall Guy. Further, the most effective time to expand your Authority is when you are negotiating the terms of a new position. Changing positions is the nuclear option. However, it is better than becoming the Fall Guy, and a change can create opportunities that will accelerate your career and influence, if done right.

When I talk about Authority/Accountability balance, I always counter the Fall Guy with an ignominious historical figure: General George B. McClellan. General McClellan was the commander of the Army of the Potomac during the early years of the American Civil War. General McClellan had the industrial might of the Union north at his beck and call, as well as extraordinary resources for recruiting and retaining soldiers for his army. At every encounter with General Robert E. Lee’s Army of Northern Virginia, General McClellan outnumbered them, sometimes by more than two to one. Yet General McClellan was outfoxed repeatedly for the same reason: He failed to take decisive action.

Every time that McClellan failed, he blamed insufficient resources and told President Lincoln that he needed more troops and more equipment to be successful. In summary, while the Fall Guy scenario needs to be avoided, once you are adequately resourced, success requires taking decisive and strategic action, or you will suffer as did General McClellan. Failing to act when you are appropriately resourced can be just as damaging to your career and credibility as allowing yourself to become the Fall Guy.
 

Job description

Everybody has somebody that they report to, no matter how high up on the executive ladder they have climbed. Even the CEO must report to the board of directors. And that reporting structure usually involves periodic formal reviews. Your formal review is a good time to go over your job description, note what is relevant, remove what is irrelevant, and add new elements that have evolved in importance since your last review.

Job descriptions take many forms, but they always include a list of qualifications. If you have the job, you have the qualifications, so that is not likely to change. You may become more qualified for a higher-level position, but that is an entirely different discussion. I like to think of a well-written job description as including short-term and long-term goals. Short-term goals are usually the daily stuff that keeps operations running smoothly but garners little attention. Examples would include staying current on your emails, answering your phone, organizing meetings, and regularly attending various committees. Even some of these short-term goals can and will change over time. I always enjoyed quality oversight in my department, but as the department and my responsibilities grew, I realized I couldn’t do everything that I wanted to do. I needed to focus on the things only I could do and delegate those things that could be done by someone else, even though I wanted to continue doing them myself. I created a position for a clinical quality officer, and quality oversight moved off of my job description.

Long-term goals are the aspirational items, such as increasing market share, decreasing readmissions, improving patient satisfaction, and the like. Effective leaders are often focused on these aspirational, long-term goals, but they still must effectively execute their short-term goals. Stephen Covey outlines the dilemma with the “time management matrix” in his seminal work “The 7 Habits of Highly Effective People.” An in-depth discussion is beyond the scope of this article, but the time management matrix places tasks into one of four categories based on urgency and importance, and provides strategies for staying up on short-term goals while continually moving long-term goals forward.If you show up at your review with a list of accomplishments as well as an understanding of how the “time management matrix” affects your responsibilities, your boss will be impressed. It is also worth mentioning that Covey’s first habit is “Proactivity.” He uses the term Proactivity in a much more nuanced form than we typically think of, however. Simply put, Proactivity is the opposite of Reactivity, and it is another invaluable tool for success with those long-term goals that will help you make a name for yourself.

When you show up for your review, be it annual, biannual, or other, be prepared. Not only should you bring your job description and recommendations for how it should be adapted in the changing environment, but also bring examples of your accomplishments since the last review.

I talk with leaders frequently who are hardworking and diligent and hate bragging about their achievements; I get that. At the same time, if you don’t inform your superiors about your successes, there is no guarantee that they will hear about them or understand them in the appropriate context. Bragging about how great you are in the physician’s lounge is annoying; telling your boss about your accomplishments since the last review is critical to maintaining the momentum of past accomplishments. If you are not willing to toot your own horn, there is a very good chance that your horn will remain silent. I don’t think self-promotion comes easily to anyone, and it has to be done with a degree of humility and sensitivity; but it has to be done, so prepare for it.
 

Look out for yourself and others

We talk about teamwork and collaboration as hospitalists, and SHM is always underscoring the importance of teamwork and highlighting examples of successful teamwork in its many conferences and publications. Most hospital executives are focused on their own careers, however, and many have no reservations about damaging your career (your brand) if they think it will promote theirs. You have to look out for yourself and size up every leadership position you get into.

Physicians can expect their careers to last decades. The average hospital CEO has a tenure of less than 3.5 years, however, and when a new CEO is hired, almost half of chief financial, chief operating, and chief information officers are fired within 9 months. You may be focused on the long-term success of your organization as you plan your career, but many hospital administrators are interested only in short-term gains. It is similar to some members of Congress who are interested only in what they need to do now to win the next election and not in the long-term needs of the country. You should understand this disconnect when dealing with hospital executives, and how you and your credibility can become cannon fodder in their quest for short-term self-preservation.

You have to look out for and take care of yourself as you promote your group. With a better understanding of the Authority/Accountability balance, you have new tools to assess your chances of success and to advocate for yourself so that you and your group can be successful.

Despite my cynicism toward executives in the medical field, I personally advocate for supporting the career development of those around you and advise against furthering your career at the expense of others. Many unscrupulous executives will use this approach, surrounding themselves with Fall Guys, but my experience shows that this is not a sustainable strategy for success. It can lead to short-term gains, but eventually the piper must be paid. Moreover, the most successful medical executives and leaders that I have encountered have been those who genuinely cared about their subordinates, looked out for them, and selflessly promoted their careers.

In the age of social media, tearing others down seems to be the fastest way to get more “likes.” However, I strongly believe that you can’t build up your group, and our profession, just by tearing people down. Lending a helping hand may bring you less attention in the short term, but such action raises your stature, creates loyalty, and leads to sustainable success for the long run.
 

Dr. McIlraith is the founding chairman of the Hospital Medicine Department at Mercy Medical Group in Sacramento, Calif. He received the SHM Award for Outstanding Service in Hospital Medicine in 2016 and is currently a member of the SHM Practice Management and Awards Committees, as well as the SHM Critical Care Task Force.

Sources

Quinn R. HM Turns 20: A look at the evolution of hospital medicine. The Hospitalist. 2016 August. https://www.the-hospitalist.org/hospitalist/article/121525/hm-turns-20-look-evolution-hospital-medicine

Stephen R. Covey. The 7 Habits of Highly Effective People: Powerful Lessons in Personal Change. Simon & Schuster. 1989.

10 Statistics on CEO Turnover, Recruitment. Becker’s Hospital Review. 2020. https://www.beckershospitalreview.com/hospital-management-administration/10-statistics-on-ceo-turnover-recruitment.html

I. Finding a mentor

Case

You are a 27-year-old first-year resident who is seeking mentorship. You are halfway through the year and are thinking about your goals and future. You have a general interest in hematology/oncology but have limited experience and would like to gain more experience with clinically relevant scholarship. However, you do not know anyone in the field and are not sure who to ask for guidance.

Stage 1: Seeking the right mentor

Start first with your area of interest and then look broadly. In this case the resident is interested in heme/onc. The first place to look is on the heme/onc department website or in the faculty directory. It can be helpful to look at what the potential mentor has published recently and/or look at a version of their CV on the faculty directory or website. This can help determine how productive they are and help assess whether you share similar interests, and whether they have worked with many learners in the past.

It is also important to do some background work and ask around about potential mentors. Often resident colleagues and fellows have a good sense of current projects and which faculty work well with learners. Lastly, it is important to also look at non–heme/onc physicians as there may be internal medicine physicians or surgeons who are doing hematology or oncology research that more align with your interests.

After you have assessed whether you think this person would be a strong mentor for you, it is time to reach out. People are flattered to be asked and part of their promotion criteria is their ability to mentor. Do not assume that a potential mentor is too busy! Let him or her make that decision. Remember the worst a mentor can say is “no.” Even if they do not have time or the need for a mentee at the present time, they generally will offer some assistance or direction on who to ask.

Start with a straightforward, but pleasant email. Waiting up to 2 weeks for a response is reasonable. If after 2 weeks you have not received word, feel free to reach out again asking politely if he or she would be willing to work with you. Do not be afraid to ask bluntly for their guidance and mentorship and have a specific project or area of research that you would like their assistance with.
 

II. Optimizing the mentor/mentee relationship

Case continued

Success! Your email was received with interest by a hematologist who has done several projects, comes highly recommended by other residents, and worked with students and residents in the past. The project involves anticoagulation on the inpatient service. You are set to meet with her next month.

Stage 2: Establishing expectations and goals

Now comes the hard work in establishing an excellent mentor/mentee relationship. Before you meet with your mentor, brainstorm first. What do you want out of the relationship? A publication? Career advice? Attaining a fellowship position? You should feel empowered in knowing that you as the mentee are in the driver seat, but this relationship should be mutually beneficial. Consider basing the relationship and initial discussions on these key questions:

1. My goals

• What are my goals? It is okay not to know but be ready to communicate some information to your mentor.
• Remember to also ask your mentor what their goals are for you as well.

2. Outcome

• What type of outcome are both you and your mentor looking for from the relationship?

3. Expectations

• What mentorship expectations do you have?
• What are your mentor’s expectations of you?

Once you feel you have a sense of what you are looking for out of the relationship, it is important to communicate this with the mentor to establish congruent expectations of one another. For example, think about asking your mentor if the two of you can establish a mentor/mentee contract. This is a written document that can be found online and establishes a mutual agreement of roles, responsibilities, and expectations of one another for the relationship. It can further help to open a line for honest and consistent feedback. This can also give you a formalized endpoint and agreed upon scope for the mentoring relationship. Having a check-in preestablished in a contract reduces any potentially awkward conversations about redefining the relationship down the road. (For example, what if our case resident decides to pursue GI? It could happen.)
 

Stage 3: Establishing a common goal

After you have determined the goals and expectations of the relationship together (remember, this is a relationship), it is time to start exploring possible projects and establishing goals for those projects. Having a quality improvement or research project will determine a common goal to work towards and help establish and define the relationship.

Once you have delineated broadly what the project(s) should be, develop smaller SMART (specific, measurable, achievable, relevant, time-bound) goals to move the project forward. These goals determine stopping points for evaluation and feedback, which further establish the relationship and keep the project(s) progressing. For example, one goal could be to write the first draft of the proposal for your quality improvement project within 3 weeks.
 

Stage 4: Continued communication

With any project it is important to stay on the same page as your mentor and be clear to establish “who is doing what by when.” Do not expect accountability to be the mentor’s job. Remember that you are in the driver’s seat and that you should propose how often you need to meet and what those meetings look like by developing an agenda. You can have an open discussion and allow your mentor to help determine a reasonable timeline. Remember, the more you communicate your goals, the better your mentor will be able to address them.

One pro tip is to always exceed your mentor’s expectations – if you think you need 2 weeks to complete a task, ask for 3-4 weeks. This gives you extra padding in case of unforeseen circumstances and makes you look like a “rockstar” if you hit a deadline 1-2 weeks earlier than planned.
 

III. Ending and/or redefining the relationship

Case continued

You are now a senior resident who’s published multiple articles in the past year, and have completed an anticoagulation project for inpatients with pulmonary emboli. You look back on your experience and what stands out is the extent of your gratitude and appreciation for your incredible mentor. Not only do you feel that your mentor has guided you in your career and with your scholarship, but you feel that he or she has shaped your character and talent set. At this point your mentor is both a teacher and guide, but now also a friend. While you feel there is always more that you can learn from her, you are ready to explore new interests. How do you effectively end or redefine this relationship?

Stage 5: Redefining your mentoring relationship

First, go back to the expectations or contract established early in the relationship. The check-in is a key time in the relationship to reevaluate goals and priorities. At this point you may decide to amicably end the relationship or project, or move on to a new project with a change in your role. For example, the quality improvement project may change to research, or you as the mentee have a change in focus (e.g., change in specialty or scholarly focus).

In summary, the interaction between you and your mentor should be a relationship. And the keys to a great relationship are:

1. Establish clear expectations from the beginning. This clarifies the relationship and helps the mentee and mentor to become more successful.

2. Maintain clear and open communication throughout the relationship.3. Define your goals and discuss them with your mentor early. (Have we mentioned the importance of goals enough?) After all, your goal is the reason you started pursuing this relationship in the first place.

In clinical training having guidance can greatly enhance your experience and direct your future career in unexpected ways. We hope that using these tools will guide you towards forging a strong mentor/mentee relationship.

Dr. Zimmerberg-Helms is a resident physician at the University of New Mexico, Albuquerque. Dr. Rendon is an attending hospitalist at the University of New Mexico.

I. Finding a mentor

Case

You are a 27-year-old first-year resident who is seeking mentorship. You are halfway through the year and are thinking about your goals and future. You have a general interest in hematology/oncology but have limited experience and would like to gain more experience with clinically relevant scholarship. However, you do not know anyone in the field and are not sure who to ask for guidance.

Stage 1: Seeking the right mentor

Start first with your area of interest and then look broadly. In this case the resident is interested in heme/onc. The first place to look is on the heme/onc department website or in the faculty directory. It can be helpful to look at what the potential mentor has published recently and/or look at a version of their CV on the faculty directory or website. This can help determine how productive they are and help assess whether you share similar interests, and whether they have worked with many learners in the past.

It is also important to do some background work and ask around about potential mentors. Often resident colleagues and fellows have a good sense of current projects and which faculty work well with learners. Lastly, it is important to also look at non–heme/onc physicians as there may be internal medicine physicians or surgeons who are doing hematology or oncology research that more align with your interests.

After you have assessed whether you think this person would be a strong mentor for you, it is time to reach out. People are flattered to be asked and part of their promotion criteria is their ability to mentor. Do not assume that a potential mentor is too busy! Let him or her make that decision. Remember the worst a mentor can say is “no.” Even if they do not have time or the need for a mentee at the present time, they generally will offer some assistance or direction on who to ask.

Start with a straightforward, but pleasant email. Waiting up to 2 weeks for a response is reasonable. If after 2 weeks you have not received word, feel free to reach out again asking politely if he or she would be willing to work with you. Do not be afraid to ask bluntly for their guidance and mentorship and have a specific project or area of research that you would like their assistance with.
 

II. Optimizing the mentor/mentee relationship

Case continued

Success! Your email was received with interest by a hematologist who has done several projects, comes highly recommended by other residents, and worked with students and residents in the past. The project involves anticoagulation on the inpatient service. You are set to meet with her next month.

Stage 2: Establishing expectations and goals

Now comes the hard work in establishing an excellent mentor/mentee relationship. Before you meet with your mentor, brainstorm first. What do you want out of the relationship? A publication? Career advice? Attaining a fellowship position? You should feel empowered in knowing that you as the mentee are in the driver seat, but this relationship should be mutually beneficial. Consider basing the relationship and initial discussions on these key questions:

1. My goals

• What are my goals? It is okay not to know but be ready to communicate some information to your mentor.
• Remember to also ask your mentor what their goals are for you as well.

2. Outcome

• What type of outcome are both you and your mentor looking for from the relationship?

3. Expectations

• What mentorship expectations do you have?
• What are your mentor’s expectations of you?

Once you feel you have a sense of what you are looking for out of the relationship, it is important to communicate this with the mentor to establish congruent expectations of one another. For example, think about asking your mentor if the two of you can establish a mentor/mentee contract. This is a written document that can be found online and establishes a mutual agreement of roles, responsibilities, and expectations of one another for the relationship. It can further help to open a line for honest and consistent feedback. This can also give you a formalized endpoint and agreed upon scope for the mentoring relationship. Having a check-in preestablished in a contract reduces any potentially awkward conversations about redefining the relationship down the road. (For example, what if our case resident decides to pursue GI? It could happen.)
 

Stage 3: Establishing a common goal

After you have determined the goals and expectations of the relationship together (remember, this is a relationship), it is time to start exploring possible projects and establishing goals for those projects. Having a quality improvement or research project will determine a common goal to work towards and help establish and define the relationship.

Once you have delineated broadly what the project(s) should be, develop smaller SMART (specific, measurable, achievable, relevant, time-bound) goals to move the project forward. These goals determine stopping points for evaluation and feedback, which further establish the relationship and keep the project(s) progressing. For example, one goal could be to write the first draft of the proposal for your quality improvement project within 3 weeks.
 

Stage 4: Continued communication

With any project it is important to stay on the same page as your mentor and be clear to establish “who is doing what by when.” Do not expect accountability to be the mentor’s job. Remember that you are in the driver’s seat and that you should propose how often you need to meet and what those meetings look like by developing an agenda. You can have an open discussion and allow your mentor to help determine a reasonable timeline. Remember, the more you communicate your goals, the better your mentor will be able to address them.

One pro tip is to always exceed your mentor’s expectations – if you think you need 2 weeks to complete a task, ask for 3-4 weeks. This gives you extra padding in case of unforeseen circumstances and makes you look like a “rockstar” if you hit a deadline 1-2 weeks earlier than planned.
 

III. Ending and/or redefining the relationship

Case continued

You are now a senior resident who’s published multiple articles in the past year, and have completed an anticoagulation project for inpatients with pulmonary emboli. You look back on your experience and what stands out is the extent of your gratitude and appreciation for your incredible mentor. Not only do you feel that your mentor has guided you in your career and with your scholarship, but you feel that he or she has shaped your character and talent set. At this point your mentor is both a teacher and guide, but now also a friend. While you feel there is always more that you can learn from her, you are ready to explore new interests. How do you effectively end or redefine this relationship?

Stage 5: Redefining your mentoring relationship

First, go back to the expectations or contract established early in the relationship. The check-in is a key time in the relationship to reevaluate goals and priorities. At this point you may decide to amicably end the relationship or project, or move on to a new project with a change in your role. For example, the quality improvement project may change to research, or you as the mentee have a change in focus (e.g., change in specialty or scholarly focus).

In summary, the interaction between you and your mentor should be a relationship. And the keys to a great relationship are:

1. Establish clear expectations from the beginning. This clarifies the relationship and helps the mentee and mentor to become more successful.

2. Maintain clear and open communication throughout the relationship.3. Define your goals and discuss them with your mentor early. (Have we mentioned the importance of goals enough?) After all, your goal is the reason you started pursuing this relationship in the first place.

In clinical training having guidance can greatly enhance your experience and direct your future career in unexpected ways. We hope that using these tools will guide you towards forging a strong mentor/mentee relationship.

Dr. Zimmerberg-Helms is a resident physician at the University of New Mexico, Albuquerque. Dr. Rendon is an attending hospitalist at the University of New Mexico.

I. Finding a mentor

Case

You are a 27-year-old first-year resident who is seeking mentorship. You are halfway through the year and are thinking about your goals and future. You have a general interest in hematology/oncology but have limited experience and would like to gain more experience with clinically relevant scholarship. However, you do not know anyone in the field and are not sure who to ask for guidance.

Stage 1: Seeking the right mentor

Start first with your area of interest and then look broadly. In this case the resident is interested in heme/onc. The first place to look is on the heme/onc department website or in the faculty directory. It can be helpful to look at what the potential mentor has published recently and/or look at a version of their CV on the faculty directory or website. This can help determine how productive they are and help assess whether you share similar interests, and whether they have worked with many learners in the past.

It is also important to do some background work and ask around about potential mentors. Often resident colleagues and fellows have a good sense of current projects and which faculty work well with learners. Lastly, it is important to also look at non–heme/onc physicians as there may be internal medicine physicians or surgeons who are doing hematology or oncology research that more align with your interests.

After you have assessed whether you think this person would be a strong mentor for you, it is time to reach out. People are flattered to be asked and part of their promotion criteria is their ability to mentor. Do not assume that a potential mentor is too busy! Let him or her make that decision. Remember the worst a mentor can say is “no.” Even if they do not have time or the need for a mentee at the present time, they generally will offer some assistance or direction on who to ask.

Start with a straightforward, but pleasant email. Waiting up to 2 weeks for a response is reasonable. If after 2 weeks you have not received word, feel free to reach out again asking politely if he or she would be willing to work with you. Do not be afraid to ask bluntly for their guidance and mentorship and have a specific project or area of research that you would like their assistance with.
 

II. Optimizing the mentor/mentee relationship

Case continued

Success! Your email was received with interest by a hematologist who has done several projects, comes highly recommended by other residents, and worked with students and residents in the past. The project involves anticoagulation on the inpatient service. You are set to meet with her next month.

Stage 2: Establishing expectations and goals

Now comes the hard work in establishing an excellent mentor/mentee relationship. Before you meet with your mentor, brainstorm first. What do you want out of the relationship? A publication? Career advice? Attaining a fellowship position? You should feel empowered in knowing that you as the mentee are in the driver seat, but this relationship should be mutually beneficial. Consider basing the relationship and initial discussions on these key questions:

1. My goals

• What are my goals? It is okay not to know but be ready to communicate some information to your mentor.
• Remember to also ask your mentor what their goals are for you as well.

2. Outcome

• What type of outcome are both you and your mentor looking for from the relationship?

3. Expectations

• What mentorship expectations do you have?
• What are your mentor’s expectations of you?

Once you feel you have a sense of what you are looking for out of the relationship, it is important to communicate this with the mentor to establish congruent expectations of one another. For example, think about asking your mentor if the two of you can establish a mentor/mentee contract. This is a written document that can be found online and establishes a mutual agreement of roles, responsibilities, and expectations of one another for the relationship. It can further help to open a line for honest and consistent feedback. This can also give you a formalized endpoint and agreed upon scope for the mentoring relationship. Having a check-in preestablished in a contract reduces any potentially awkward conversations about redefining the relationship down the road. (For example, what if our case resident decides to pursue GI? It could happen.)
 

Stage 3: Establishing a common goal

After you have determined the goals and expectations of the relationship together (remember, this is a relationship), it is time to start exploring possible projects and establishing goals for those projects. Having a quality improvement or research project will determine a common goal to work towards and help establish and define the relationship.

Once you have delineated broadly what the project(s) should be, develop smaller SMART (specific, measurable, achievable, relevant, time-bound) goals to move the project forward. These goals determine stopping points for evaluation and feedback, which further establish the relationship and keep the project(s) progressing. For example, one goal could be to write the first draft of the proposal for your quality improvement project within 3 weeks.
 

Stage 4: Continued communication

With any project it is important to stay on the same page as your mentor and be clear to establish “who is doing what by when.” Do not expect accountability to be the mentor’s job. Remember that you are in the driver’s seat and that you should propose how often you need to meet and what those meetings look like by developing an agenda. You can have an open discussion and allow your mentor to help determine a reasonable timeline. Remember, the more you communicate your goals, the better your mentor will be able to address them.

One pro tip is to always exceed your mentor’s expectations – if you think you need 2 weeks to complete a task, ask for 3-4 weeks. This gives you extra padding in case of unforeseen circumstances and makes you look like a “rockstar” if you hit a deadline 1-2 weeks earlier than planned.
 

III. Ending and/or redefining the relationship

Case continued

You are now a senior resident who’s published multiple articles in the past year, and have completed an anticoagulation project for inpatients with pulmonary emboli. You look back on your experience and what stands out is the extent of your gratitude and appreciation for your incredible mentor. Not only do you feel that your mentor has guided you in your career and with your scholarship, but you feel that he or she has shaped your character and talent set. At this point your mentor is both a teacher and guide, but now also a friend. While you feel there is always more that you can learn from her, you are ready to explore new interests. How do you effectively end or redefine this relationship?

Stage 5: Redefining your mentoring relationship

First, go back to the expectations or contract established early in the relationship. The check-in is a key time in the relationship to reevaluate goals and priorities. At this point you may decide to amicably end the relationship or project, or move on to a new project with a change in your role. For example, the quality improvement project may change to research, or you as the mentee have a change in focus (e.g., change in specialty or scholarly focus).

In summary, the interaction between you and your mentor should be a relationship. And the keys to a great relationship are:

1. Establish clear expectations from the beginning. This clarifies the relationship and helps the mentee and mentor to become more successful.

2. Maintain clear and open communication throughout the relationship.3. Define your goals and discuss them with your mentor early. (Have we mentioned the importance of goals enough?) After all, your goal is the reason you started pursuing this relationship in the first place.

In clinical training having guidance can greatly enhance your experience and direct your future career in unexpected ways. We hope that using these tools will guide you towards forging a strong mentor/mentee relationship.

Dr. Zimmerberg-Helms is a resident physician at the University of New Mexico, Albuquerque. Dr. Rendon is an attending hospitalist at the University of New Mexico.

The COVID-19 pandemic has thrown a monkey wrench into the medical education landscape across the entire health care spectrum, disrupting the plans of medical students, residents, fellows, and program directors.

As cases of COVID-19 spread across the United States in early 2020, it became clear to training program directors that immediate action was required to meet the needs of medical learners. The challenges were unlike those surrounding the Ebola virus in 2014, “where we could more easily prevent students and trainees from exposure due to the fact that there were simply not significant numbers of cases in the United States,” Tiffany Murano, MD, said at a Society for Critical Care virtual meeting: COVID-19: What’s Next. Dr. Murano is professor of emergency medicine at Rutgers New Jersey Medical School, Newark, and president-elect of the Council of Residency Directors in Emergency Medicine. “COVID was a completely different scenario. We quickly realized that not only was personal protective equipment in short supply, but we also lacked the testing and tracking capabilities for potential exposures. Medical students and other supportive workers who were considered nonessential were removed from the clinical setting. This was after a trial of limiting who the students saw, essentially dampening the risk of exposure. But this proved to be flawed as COVID patients presented with symptoms that were unexpected.”

To complicate matters, she continued, many medical clinics either shut down, had limited access, or converted to telemedicine. Elective surgeries were canceled. This led to an overall pause in clinical medical student rotations and no direct patient care activities. As social distancing mandates were instituted, licensing examination testing centers were closed, and exams and on-campus activities were postponed.
 

Limiting trainee exposure

On the graduate medical education front, some training programs attempted to limit exposure of their trainees to persons under investigation for COVID-19. “As the number of COVID cases grew and encompassed most of what we were seeing in the hospital, it was obvious that residents had to play a vital part in the care of these patients,” said Dr. Murano, who is also a member of the American Council of Graduate Medical Education’s emergency review and recognition committee. “However, there was a consensus among all of the specialties that the procedures that posed the highest risk of exposure would be limited to the most senior or experienced trainees or professionals, and closely supervised by the faculty.”

ACGME activities such as accreditation site visits, clinical environment learning reviews, self-study, and resident and faculty surveys were suspended, postponed, or modified in some way, she said. The ACGME created stages of COVID status to guide sponsoring institutions to suspend learning curricula in order for patients to be cared for. Stage 1 was business as usual, “so there was no significant impact on patient care,” Dr. Murano said. “Stage 2 was increased but manageable clinical demand, while stage 3 was pandemic emergency status, where there were extraordinary circumstances where the clinical demand was so high and strenuous that the routine patient care and education really needed to be reconfigured in order to care for the patients.”

New requirements to manage training

The ACGME also implemented four requirements to manage training that were consistent among institutions, regardless of their COVID stage status. These included making sure that trainees continued to be held to work-hour limit requirements, ensuring adequate resources for training, ensuring that all residents had the appropriate level of supervision at all times, and allowing fellows to function in the core specialty in which they completed their residency training. “This was only possible if the fellows were ABMS [American Board of Medical Specialties] or AOA [American Osteopathic Association] board-eligible, or certified in their core specialty,” Dr. Murano said. “The fellows had to be appointed to the medical staff at the sponsoring institution, and their time spent on the core specialty service would be limited to 20% of their annual education time in any academic year.”

Mindful that there may have been trainees who required a 2-week quarantine period following exposure or potential exposure to COVID-19, some specialty boards showed leniency in residency time required to sit for the written exam. “Testing centers were being forced to close to observe social distancing requirements and heed sanitation recommendations, so exams were either canceled or postponed,” Dr. Murano said. “This posed a special concern for the board certification process, and those specialties with oral examinations had to make a heavy decision regarding whether or not they would allow these exams to take place. Naturally, travel among institutions was suspended or limited, or had quarantine requirements upon returning home from endemic areas. Conferences were either being canceled or converted to virtual formats.”

Subani Chandra, MD, FCCP, of the division of pulmonary, allergy, and critical care medicine at Columbia University, New York, is the internal medicine residency program director and the associate vice-chair of education for the department of medicine, and she recognized the problem created for medical trainees by the changes necessitated by the pandemic.

“The variability in caseloads and clinical exposure has given thrust to the move toward competency-based assessments rather than number- or time-based criteria for determining proficiency and graduation,” she wrote in an email interview. In addition, she noted the impact on medical meetings and the need to adapt. “Early on, before large regional and national conferences adapted to a virtual format, many were canceled altogether. Students, residents, and fellows expecting to have the opportunity to present their scholarly work were suddenly no longer able to do so. Understanding the importance of scholarly interaction, the virtual format of CHEST 2020 is designed with opportunities to present, interact with experts in the field, ask questions, network, and meet mentors.”

No return to ‘normal’

By April 2020, cases in the northeast continued to rise, particularly in the New York, New Jersey, and Connecticut region. “These states were essentially shut down in order to contain spread of the virus,” she said. “This was a real turning point because we realized that things were not going to return to ‘normal’ in the foreseeable future.” With the clinical experience essentially halted for medical students during this time, some medical schools allowed their senior students who met requirements to graduate early. “There were a lot of mixed feelings about this, recognizing that PPE [personal protective equipment] was still in short supply in many areas,” Dr. Murano said. “So, institutions took on these early graduates into roles in which they were not learners in particular, but rather medical workers. They were helping with informatics and technology, telehealth, virtual or telephone call follow-ups, and other tasks like this. There was a movement to virtual learning for the preclinical undergraduate learners, so classes were now online, recorded, or livestreamed.”
 

Early graduation, matching, and residencies

On April 3, the ACGME released a statement regarding graduating students early and appointing them early to the clinical learning environment. “They pointed out that institutions that were in emergency pandemic status lacked the ability to offer the comprehensive orientation and training in PPE and direct supervision required for new residents at the start of their residency,” Dr. Murano said. “Their opinion maintained that graduating medical students matriculate in their previously matched program, the National Resident Match Program start date, or other date that would be nationally determined to be the beginning of the 2020-2021 academic year.”

As May 2020 rolled around, the overriding feeling was uncertainty regarding when, if, and how medical schools were going to open in the early summer and fall. “There was also uncertainty about how graduating medical students were going to function in their new role as residents,” she said. “Same for the graduating residents. There were some who had signed contracts for jobs months before, and had them rescinded, and physicians were being furloughed due to financial hardships that institutions faced. There was also postponement of board certification exams, so people were uncertain about when they would become board certified.”

July 2020 ushered in what Dr. Murano characterized as “a whole new level of stress.” For medical students in particular, “we were entering the application season for residency positions,” she said. “Due to travel restrictions placed by various states and institutions, away rotations were limited or nonexistent. Application release dates through the Electronic Residency Application Service were moved to later in the year. The United States Medical Licensing Examination clinical skills exam was suspended, and there were modifications made for Education Commission for Foreign Medical Graduates requirements. Letters of recommendation were also going to be limited, so there had to be some degree of leniency within specialties to take a more holistic approach to review of applications for residencies.”

On the graduate medical education front, the ACGME sunsetted the initial stages and created two categories: nonemergency, which was formerly stages 1 and 2, and emergency, which was formerly stage 3. “All emergency stages are applied for and granted at 1-month intervals,” Dr. Murano said. Board certification exams were modified to accommodate either later exams or online formats, and specialties with oral examinations faced the task of potentially creating virtual oral exams.

Despite the challenges, Dr. Chandra has seen medical training programs respond with new ideas. “The flexibility and agile adaptability of the entire educational enterprise has been remarkable. The inherent uncertainty in a very dynamic and changing learning environment can be challenging. Recognizing this, many programs are creating additional ways to support the mental, emotional, physical, and financial health of students, residents, and fellows and all health care workers. The importance of this innovative response cannot be overstated.”
 

New learning formats

The pandemic forced Dr. Murano and other medical educators to consider unorthodox learning formats, and virtual learning took center stage. “Residency programs had shared national livestream conferences and grand rounds, and there were virtual curricula made for medical students as well as virtual simulation,” she said. “Telemedicine and telehealth really became important parts of education as well, as this may have been the only face-to-face contact that students and residents had with patients who had non–COVID-related complaints.”

To level the playing field for medical residents during this unprecedented time, a work group of the Coalition for Physician Accountability developed a set of recommendations that include limiting the number of letters of recommendation accepted, limiting the number of away rotations, and allowing alternative or less conventional letters of recommendation. “Keeping an open mind and taking a more holistic approach to applicants has really been needed during this time,” Dr. Murano said. “Virtual interview days have been agreed upon for all specialties. They’re safer, and they allow for students to virtually meet faculty and residents from distant programs that in the past would have been a deterrent due to distance and travel costs. This is not without its own downside, as it’s difficult to determine how well a student will fit into a program without [him or her] actually visiting the institution.”

Dr. Chandra agreed that virtual interviews are necessary but have inherent limitations. However, “we will all learn a lot, and very likely the future process will blend the benefits of both virtual and in-person interviews.”
 

‘We need to keep moving forward’

Dr. Murano concluded her presentation by noting that the COVID-19 pandemic has created opportunities for growth and innovation in medical education, “so we need to keep moving forward. I’ve heard many say that they can’t wait for things to go back to normal. But I think it’s important to go ahead to new and better ways of learning. We’re now thinking outside of the typical education model and are embracing technology and alternative means of education. We don’t know yet if this education is better, worse, or equivalent to traditional methods, but that will be determined and studied in months and years to come, so we’re certainly looking to the future.”

Dr. Murano and Dr. Chandra reported having no financial disclosures.

[email protected]

The COVID-19 pandemic has thrown a monkey wrench into the medical education landscape across the entire health care spectrum, disrupting the plans of medical students, residents, fellows, and program directors.

As cases of COVID-19 spread across the United States in early 2020, it became clear to training program directors that immediate action was required to meet the needs of medical learners. The challenges were unlike those surrounding the Ebola virus in 2014, “where we could more easily prevent students and trainees from exposure due to the fact that there were simply not significant numbers of cases in the United States,” Tiffany Murano, MD, said at a Society for Critical Care virtual meeting: COVID-19: What’s Next. Dr. Murano is professor of emergency medicine at Rutgers New Jersey Medical School, Newark, and president-elect of the Council of Residency Directors in Emergency Medicine. “COVID was a completely different scenario. We quickly realized that not only was personal protective equipment in short supply, but we also lacked the testing and tracking capabilities for potential exposures. Medical students and other supportive workers who were considered nonessential were removed from the clinical setting. This was after a trial of limiting who the students saw, essentially dampening the risk of exposure. But this proved to be flawed as COVID patients presented with symptoms that were unexpected.”

To complicate matters, she continued, many medical clinics either shut down, had limited access, or converted to telemedicine. Elective surgeries were canceled. This led to an overall pause in clinical medical student rotations and no direct patient care activities. As social distancing mandates were instituted, licensing examination testing centers were closed, and exams and on-campus activities were postponed.
 

Limiting trainee exposure

On the graduate medical education front, some training programs attempted to limit exposure of their trainees to persons under investigation for COVID-19. “As the number of COVID cases grew and encompassed most of what we were seeing in the hospital, it was obvious that residents had to play a vital part in the care of these patients,” said Dr. Murano, who is also a member of the American Council of Graduate Medical Education’s emergency review and recognition committee. “However, there was a consensus among all of the specialties that the procedures that posed the highest risk of exposure would be limited to the most senior or experienced trainees or professionals, and closely supervised by the faculty.”

ACGME activities such as accreditation site visits, clinical environment learning reviews, self-study, and resident and faculty surveys were suspended, postponed, or modified in some way, she said. The ACGME created stages of COVID status to guide sponsoring institutions to suspend learning curricula in order for patients to be cared for. Stage 1 was business as usual, “so there was no significant impact on patient care,” Dr. Murano said. “Stage 2 was increased but manageable clinical demand, while stage 3 was pandemic emergency status, where there were extraordinary circumstances where the clinical demand was so high and strenuous that the routine patient care and education really needed to be reconfigured in order to care for the patients.”

New requirements to manage training

The ACGME also implemented four requirements to manage training that were consistent among institutions, regardless of their COVID stage status. These included making sure that trainees continued to be held to work-hour limit requirements, ensuring adequate resources for training, ensuring that all residents had the appropriate level of supervision at all times, and allowing fellows to function in the core specialty in which they completed their residency training. “This was only possible if the fellows were ABMS [American Board of Medical Specialties] or AOA [American Osteopathic Association] board-eligible, or certified in their core specialty,” Dr. Murano said. “The fellows had to be appointed to the medical staff at the sponsoring institution, and their time spent on the core specialty service would be limited to 20% of their annual education time in any academic year.”

Mindful that there may have been trainees who required a 2-week quarantine period following exposure or potential exposure to COVID-19, some specialty boards showed leniency in residency time required to sit for the written exam. “Testing centers were being forced to close to observe social distancing requirements and heed sanitation recommendations, so exams were either canceled or postponed,” Dr. Murano said. “This posed a special concern for the board certification process, and those specialties with oral examinations had to make a heavy decision regarding whether or not they would allow these exams to take place. Naturally, travel among institutions was suspended or limited, or had quarantine requirements upon returning home from endemic areas. Conferences were either being canceled or converted to virtual formats.”

Subani Chandra, MD, FCCP, of the division of pulmonary, allergy, and critical care medicine at Columbia University, New York, is the internal medicine residency program director and the associate vice-chair of education for the department of medicine, and she recognized the problem created for medical trainees by the changes necessitated by the pandemic.

“The variability in caseloads and clinical exposure has given thrust to the move toward competency-based assessments rather than number- or time-based criteria for determining proficiency and graduation,” she wrote in an email interview. In addition, she noted the impact on medical meetings and the need to adapt. “Early on, before large regional and national conferences adapted to a virtual format, many were canceled altogether. Students, residents, and fellows expecting to have the opportunity to present their scholarly work were suddenly no longer able to do so. Understanding the importance of scholarly interaction, the virtual format of CHEST 2020 is designed with opportunities to present, interact with experts in the field, ask questions, network, and meet mentors.”

No return to ‘normal’

By April 2020, cases in the northeast continued to rise, particularly in the New York, New Jersey, and Connecticut region. “These states were essentially shut down in order to contain spread of the virus,” she said. “This was a real turning point because we realized that things were not going to return to ‘normal’ in the foreseeable future.” With the clinical experience essentially halted for medical students during this time, some medical schools allowed their senior students who met requirements to graduate early. “There were a lot of mixed feelings about this, recognizing that PPE [personal protective equipment] was still in short supply in many areas,” Dr. Murano said. “So, institutions took on these early graduates into roles in which they were not learners in particular, but rather medical workers. They were helping with informatics and technology, telehealth, virtual or telephone call follow-ups, and other tasks like this. There was a movement to virtual learning for the preclinical undergraduate learners, so classes were now online, recorded, or livestreamed.”
 

Early graduation, matching, and residencies

On April 3, the ACGME released a statement regarding graduating students early and appointing them early to the clinical learning environment. “They pointed out that institutions that were in emergency pandemic status lacked the ability to offer the comprehensive orientation and training in PPE and direct supervision required for new residents at the start of their residency,” Dr. Murano said. “Their opinion maintained that graduating medical students matriculate in their previously matched program, the National Resident Match Program start date, or other date that would be nationally determined to be the beginning of the 2020-2021 academic year.”

As May 2020 rolled around, the overriding feeling was uncertainty regarding when, if, and how medical schools were going to open in the early summer and fall. “There was also uncertainty about how graduating medical students were going to function in their new role as residents,” she said. “Same for the graduating residents. There were some who had signed contracts for jobs months before, and had them rescinded, and physicians were being furloughed due to financial hardships that institutions faced. There was also postponement of board certification exams, so people were uncertain about when they would become board certified.”

July 2020 ushered in what Dr. Murano characterized as “a whole new level of stress.” For medical students in particular, “we were entering the application season for residency positions,” she said. “Due to travel restrictions placed by various states and institutions, away rotations were limited or nonexistent. Application release dates through the Electronic Residency Application Service were moved to later in the year. The United States Medical Licensing Examination clinical skills exam was suspended, and there were modifications made for Education Commission for Foreign Medical Graduates requirements. Letters of recommendation were also going to be limited, so there had to be some degree of leniency within specialties to take a more holistic approach to review of applications for residencies.”

On the graduate medical education front, the ACGME sunsetted the initial stages and created two categories: nonemergency, which was formerly stages 1 and 2, and emergency, which was formerly stage 3. “All emergency stages are applied for and granted at 1-month intervals,” Dr. Murano said. Board certification exams were modified to accommodate either later exams or online formats, and specialties with oral examinations faced the task of potentially creating virtual oral exams.

Despite the challenges, Dr. Chandra has seen medical training programs respond with new ideas. “The flexibility and agile adaptability of the entire educational enterprise has been remarkable. The inherent uncertainty in a very dynamic and changing learning environment can be challenging. Recognizing this, many programs are creating additional ways to support the mental, emotional, physical, and financial health of students, residents, and fellows and all health care workers. The importance of this innovative response cannot be overstated.”
 

New learning formats

The pandemic forced Dr. Murano and other medical educators to consider unorthodox learning formats, and virtual learning took center stage. “Residency programs had shared national livestream conferences and grand rounds, and there were virtual curricula made for medical students as well as virtual simulation,” she said. “Telemedicine and telehealth really became important parts of education as well, as this may have been the only face-to-face contact that students and residents had with patients who had non–COVID-related complaints.”

To level the playing field for medical residents during this unprecedented time, a work group of the Coalition for Physician Accountability developed a set of recommendations that include limiting the number of letters of recommendation accepted, limiting the number of away rotations, and allowing alternative or less conventional letters of recommendation. “Keeping an open mind and taking a more holistic approach to applicants has really been needed during this time,” Dr. Murano said. “Virtual interview days have been agreed upon for all specialties. They’re safer, and they allow for students to virtually meet faculty and residents from distant programs that in the past would have been a deterrent due to distance and travel costs. This is not without its own downside, as it’s difficult to determine how well a student will fit into a program without [him or her] actually visiting the institution.”

Dr. Chandra agreed that virtual interviews are necessary but have inherent limitations. However, “we will all learn a lot, and very likely the future process will blend the benefits of both virtual and in-person interviews.”
 

‘We need to keep moving forward’

Dr. Murano concluded her presentation by noting that the COVID-19 pandemic has created opportunities for growth and innovation in medical education, “so we need to keep moving forward. I’ve heard many say that they can’t wait for things to go back to normal. But I think it’s important to go ahead to new and better ways of learning. We’re now thinking outside of the typical education model and are embracing technology and alternative means of education. We don’t know yet if this education is better, worse, or equivalent to traditional methods, but that will be determined and studied in months and years to come, so we’re certainly looking to the future.”

Dr. Murano and Dr. Chandra reported having no financial disclosures.

[email protected]

The COVID-19 pandemic has thrown a monkey wrench into the medical education landscape across the entire health care spectrum, disrupting the plans of medical students, residents, fellows, and program directors.

As cases of COVID-19 spread across the United States in early 2020, it became clear to training program directors that immediate action was required to meet the needs of medical learners. The challenges were unlike those surrounding the Ebola virus in 2014, “where we could more easily prevent students and trainees from exposure due to the fact that there were simply not significant numbers of cases in the United States,” Tiffany Murano, MD, said at a Society for Critical Care virtual meeting: COVID-19: What’s Next. Dr. Murano is professor of emergency medicine at Rutgers New Jersey Medical School, Newark, and president-elect of the Council of Residency Directors in Emergency Medicine. “COVID was a completely different scenario. We quickly realized that not only was personal protective equipment in short supply, but we also lacked the testing and tracking capabilities for potential exposures. Medical students and other supportive workers who were considered nonessential were removed from the clinical setting. This was after a trial of limiting who the students saw, essentially dampening the risk of exposure. But this proved to be flawed as COVID patients presented with symptoms that were unexpected.”

To complicate matters, she continued, many medical clinics either shut down, had limited access, or converted to telemedicine. Elective surgeries were canceled. This led to an overall pause in clinical medical student rotations and no direct patient care activities. As social distancing mandates were instituted, licensing examination testing centers were closed, and exams and on-campus activities were postponed.
 

Limiting trainee exposure

On the graduate medical education front, some training programs attempted to limit exposure of their trainees to persons under investigation for COVID-19. “As the number of COVID cases grew and encompassed most of what we were seeing in the hospital, it was obvious that residents had to play a vital part in the care of these patients,” said Dr. Murano, who is also a member of the American Council of Graduate Medical Education’s emergency review and recognition committee. “However, there was a consensus among all of the specialties that the procedures that posed the highest risk of exposure would be limited to the most senior or experienced trainees or professionals, and closely supervised by the faculty.”

ACGME activities such as accreditation site visits, clinical environment learning reviews, self-study, and resident and faculty surveys were suspended, postponed, or modified in some way, she said. The ACGME created stages of COVID status to guide sponsoring institutions to suspend learning curricula in order for patients to be cared for. Stage 1 was business as usual, “so there was no significant impact on patient care,” Dr. Murano said. “Stage 2 was increased but manageable clinical demand, while stage 3 was pandemic emergency status, where there were extraordinary circumstances where the clinical demand was so high and strenuous that the routine patient care and education really needed to be reconfigured in order to care for the patients.”

New requirements to manage training

The ACGME also implemented four requirements to manage training that were consistent among institutions, regardless of their COVID stage status. These included making sure that trainees continued to be held to work-hour limit requirements, ensuring adequate resources for training, ensuring that all residents had the appropriate level of supervision at all times, and allowing fellows to function in the core specialty in which they completed their residency training. “This was only possible if the fellows were ABMS [American Board of Medical Specialties] or AOA [American Osteopathic Association] board-eligible, or certified in their core specialty,” Dr. Murano said. “The fellows had to be appointed to the medical staff at the sponsoring institution, and their time spent on the core specialty service would be limited to 20% of their annual education time in any academic year.”

Mindful that there may have been trainees who required a 2-week quarantine period following exposure or potential exposure to COVID-19, some specialty boards showed leniency in residency time required to sit for the written exam. “Testing centers were being forced to close to observe social distancing requirements and heed sanitation recommendations, so exams were either canceled or postponed,” Dr. Murano said. “This posed a special concern for the board certification process, and those specialties with oral examinations had to make a heavy decision regarding whether or not they would allow these exams to take place. Naturally, travel among institutions was suspended or limited, or had quarantine requirements upon returning home from endemic areas. Conferences were either being canceled or converted to virtual formats.”

Subani Chandra, MD, FCCP, of the division of pulmonary, allergy, and critical care medicine at Columbia University, New York, is the internal medicine residency program director and the associate vice-chair of education for the department of medicine, and she recognized the problem created for medical trainees by the changes necessitated by the pandemic.

“The variability in caseloads and clinical exposure has given thrust to the move toward competency-based assessments rather than number- or time-based criteria for determining proficiency and graduation,” she wrote in an email interview. In addition, she noted the impact on medical meetings and the need to adapt. “Early on, before large regional and national conferences adapted to a virtual format, many were canceled altogether. Students, residents, and fellows expecting to have the opportunity to present their scholarly work were suddenly no longer able to do so. Understanding the importance of scholarly interaction, the virtual format of CHEST 2020 is designed with opportunities to present, interact with experts in the field, ask questions, network, and meet mentors.”

No return to ‘normal’

By April 2020, cases in the northeast continued to rise, particularly in the New York, New Jersey, and Connecticut region. “These states were essentially shut down in order to contain spread of the virus,” she said. “This was a real turning point because we realized that things were not going to return to ‘normal’ in the foreseeable future.” With the clinical experience essentially halted for medical students during this time, some medical schools allowed their senior students who met requirements to graduate early. “There were a lot of mixed feelings about this, recognizing that PPE [personal protective equipment] was still in short supply in many areas,” Dr. Murano said. “So, institutions took on these early graduates into roles in which they were not learners in particular, but rather medical workers. They were helping with informatics and technology, telehealth, virtual or telephone call follow-ups, and other tasks like this. There was a movement to virtual learning for the preclinical undergraduate learners, so classes were now online, recorded, or livestreamed.”
 

Early graduation, matching, and residencies

On April 3, the ACGME released a statement regarding graduating students early and appointing them early to the clinical learning environment. “They pointed out that institutions that were in emergency pandemic status lacked the ability to offer the comprehensive orientation and training in PPE and direct supervision required for new residents at the start of their residency,” Dr. Murano said. “Their opinion maintained that graduating medical students matriculate in their previously matched program, the National Resident Match Program start date, or other date that would be nationally determined to be the beginning of the 2020-2021 academic year.”

As May 2020 rolled around, the overriding feeling was uncertainty regarding when, if, and how medical schools were going to open in the early summer and fall. “There was also uncertainty about how graduating medical students were going to function in their new role as residents,” she said. “Same for the graduating residents. There were some who had signed contracts for jobs months before, and had them rescinded, and physicians were being furloughed due to financial hardships that institutions faced. There was also postponement of board certification exams, so people were uncertain about when they would become board certified.”

July 2020 ushered in what Dr. Murano characterized as “a whole new level of stress.” For medical students in particular, “we were entering the application season for residency positions,” she said. “Due to travel restrictions placed by various states and institutions, away rotations were limited or nonexistent. Application release dates through the Electronic Residency Application Service were moved to later in the year. The United States Medical Licensing Examination clinical skills exam was suspended, and there were modifications made for Education Commission for Foreign Medical Graduates requirements. Letters of recommendation were also going to be limited, so there had to be some degree of leniency within specialties to take a more holistic approach to review of applications for residencies.”

On the graduate medical education front, the ACGME sunsetted the initial stages and created two categories: nonemergency, which was formerly stages 1 and 2, and emergency, which was formerly stage 3. “All emergency stages are applied for and granted at 1-month intervals,” Dr. Murano said. Board certification exams were modified to accommodate either later exams or online formats, and specialties with oral examinations faced the task of potentially creating virtual oral exams.

Despite the challenges, Dr. Chandra has seen medical training programs respond with new ideas. “The flexibility and agile adaptability of the entire educational enterprise has been remarkable. The inherent uncertainty in a very dynamic and changing learning environment can be challenging. Recognizing this, many programs are creating additional ways to support the mental, emotional, physical, and financial health of students, residents, and fellows and all health care workers. The importance of this innovative response cannot be overstated.”
 

New learning formats

The pandemic forced Dr. Murano and other medical educators to consider unorthodox learning formats, and virtual learning took center stage. “Residency programs had shared national livestream conferences and grand rounds, and there were virtual curricula made for medical students as well as virtual simulation,” she said. “Telemedicine and telehealth really became important parts of education as well, as this may have been the only face-to-face contact that students and residents had with patients who had non–COVID-related complaints.”

To level the playing field for medical residents during this unprecedented time, a work group of the Coalition for Physician Accountability developed a set of recommendations that include limiting the number of letters of recommendation accepted, limiting the number of away rotations, and allowing alternative or less conventional letters of recommendation. “Keeping an open mind and taking a more holistic approach to applicants has really been needed during this time,” Dr. Murano said. “Virtual interview days have been agreed upon for all specialties. They’re safer, and they allow for students to virtually meet faculty and residents from distant programs that in the past would have been a deterrent due to distance and travel costs. This is not without its own downside, as it’s difficult to determine how well a student will fit into a program without [him or her] actually visiting the institution.”

Dr. Chandra agreed that virtual interviews are necessary but have inherent limitations. However, “we will all learn a lot, and very likely the future process will blend the benefits of both virtual and in-person interviews.”
 

‘We need to keep moving forward’

Dr. Murano concluded her presentation by noting that the COVID-19 pandemic has created opportunities for growth and innovation in medical education, “so we need to keep moving forward. I’ve heard many say that they can’t wait for things to go back to normal. But I think it’s important to go ahead to new and better ways of learning. We’re now thinking outside of the typical education model and are embracing technology and alternative means of education. We don’t know yet if this education is better, worse, or equivalent to traditional methods, but that will be determined and studied in months and years to come, so we’re certainly looking to the future.”

Dr. Murano and Dr. Chandra reported having no financial disclosures.

[email protected]

There are many challenges facing modern medicine today. Recent events have highlighted important issues affecting our society as a whole – systemic racism, sexism, and implicit bias. In medicine, we have seen a renewed focus on health equity, health disparities and the implicit systemic bias that affect those who work in the field. It is truly troubling that it has taken the continued loss of black lives to police brutality and a pandemic for this conversation to happen at every level in society.

Systemic bias is present throughout corporate America, and it is no different within the physician workforce. Overall, there has been gradual interest in promoting and teaching diversity. Institutions have been slowly creating policies and administrative positions focused on inclusion and diversity over the last decade. So has diversity training objectively increased representation and advancement of women and minority groups? Do traditionally marginalized groups have better access to health? And are women and people of color (POC) represented equally in leadership positions in medicine?

Clearly, the answers are not straightforward.
 

Diving into the data

A guilty pleasure of mine is to assess how diverse and inclusive an institution is by looking at the wall of pictures recognizing top leadership in hospitals. Despite women accounting for 47.9% of graduates from medical school in 2018-2019, I still see very few women or POC elevated to this level. Of the total women graduates, 22.6% were Asian, 8% were Black and 5.4% were Hispanic.

Being of Indian descent, I am a woman of color (albeit one who may not be as profoundly affected by racism in medicine as my less represented colleagues). It is especially rare for me to see someone I can identify with in the ranks of top leadership. I find encouragement in seeing any woman on any leadership board because to me, it means that there is hope. The literature seems to support this degree of disparity as well. For example, a recent analysis shows that presidential leadership in medical societies are predominantly held by men (82.6% male vs. 17.4% female). Other datasets demonstrate that only 15% of deans and interim deans are women and AAMC’s report shows that women account for only 18% of all department chairs.

Growing up, my parents fueled my interest to pursue medicine. They described it as a noble profession that rewarded true merit and dedication to the cause. However, those that have been traditionally elevated in medicine are men. If merit knows no gender, why does a gender gap exist? If merit is blind to race, why are minorities so poorly represented in the workforce (much less in leadership)? My view of the wall leaves me wondering about the role of both sexism and racism in medicine.

These visual representations of the medical culture reinforce the acceptable norms and values – white and masculine – in medicine. The feminist movement over the last several decades has increased awareness about the need for equality of the sexes. However, it was not until the concept of intersectionality was introduced by Black feminist Professor Kimberle Crenshaw, that feminism become a more inclusive term. Professor Crenshaw’s paper details how every individual has intersecting factors – race, gender, sexual identity, socioeconomic status – that create the sum of their experience be it privilege, oppression, or discrimination.

For example, a White woman has privileges that a woman of color does not. Among non-white women, race and sexual identity are confounding factors – a Black woman, a Black LGBTQ woman, and an Asian woman, for example, will not experience discrimination in the same way. The farther you deviate from the accepted norms and values, the harder it is for you to obtain support and achieve recognition.
 

Addressing the patriarchal structure and systemic bias in medicine

Why do patriarchal structures still exist in medicine? How do we resolve systemic bias? Addressing them in isolation – race or gender or sexual identity – is unlikely to create long-lasting change. For change to occur, organizations and individuals need to be intrinsically motivated. Creating awareness and challenging the status quo is the first step.

Over the last decade, implicit bias training and diversity training have become mandatory in various industries and states. Diversity training has grown to be a multi-billion-dollar industry that corporate America has embraced over the last several years. And yet, research shows that mandating such training may not be the most effective. To get results, organizations need to implement programs that “spark engagement, increase contact between different groups and draw on people’s desire to look good to others.”

Historically, the medical curriculum has not included a discourse on feminist theories and the advancement of women in medicine. Cultural competency training is typically offered on an annual basis once we are in the workforce, but in my experience, it focuses more on our interactions with patients and other health care colleagues, and less with regards to our physician peers and leadership. Is this enough to change deep rooted beliefs and traditions?

We can take our cue from non-medical organizations and consider changing this culture of no culture in medicine – introducing diversity task forces that hold departments accountable for recruiting and promoting women and minorities; employing diversity managers; voluntary training; cross-training to increase contact among different groups and mentoring programs that match senior leadership to women and POC. While some medical institutions have implemented some of these principles, changing century-old traditions will require embracing concepts of organizational change and every available effective tool.
 

Committing to change

Change is especially hard when the target outcome is not accurately quantifiable – even if you can measure attitudes, values, and beliefs, these are subject to reporting bias and tokenism. At the organizational level, change management involves employing a systematic approach to change organizational values, goals, policies, and processes.

Individual change, self-reflection, and personal growth are key components in changing culture. Reflexivity is being aware of your own values, norms, position, and power – an important concept to understand and apply in our everyday interactions. Believing that one’s class, gender, race and sexual orientation are irrelevant to their practice of medicine would not foster the change that we direly need in medicine. Rather, identifying how your own values and professional identity are shaped by your medical training, your organization and the broader cultural context are critically important to developing a greater empathic sense to motivate systemic change.

There has been valuable discussion on bottom-up changes to ensure women and POC have support, encouragement and a pathway to advance in an organization. Some of these include policy and process changes including providing flexible working conditions for women and sponsorship of women and minorities to help them navigate the barriers and microaggressions they encounter at work. While technical (policy) changes form the foundation for any organizational change, it is important to remember that the people side of change – the resistance that you encounter for any change effort in an organization – is equally important to address at the organizational level. A top-down approach is also vital to ensure that change is permanent in an organization and does not end when the individuals responsible for the change leave the organization.

Lewin’s three-stage change management model provides a framework for structural and organizational change in hospital systems. The three-stages of this model are: unfreezing, changing, and refreezing. Unfreezing is the process of determining what needs to change and obtaining leadership support. The actual change process involves getting people on board, empowering them to change and communicating with them frequently. Refreezing cements this change into the organization’s culture by providing support and training to sustain changes. Research has shown that Lewin’s change management model has applicability in the hospital setting.

Industry research in change management methodologies in the business sector has identified sponsorship by CEOs/senior management of an organization and having a structured implementation model for change management as two important factors for ensuring that change efforts are successful and sustainable.

This can be extrapolated to health care organizations – top leadership committed to changing the status quo should solidify organizational commitment by incorporating new attainable and measurable goals into their vision for the organization. Designing a phased implementation of change management methodologies should follow an open discussion to identify an organization’s weaknesses, strengths, capacity, and readiness for change. Lastly, helping busy professionals adapt to change requires innovative and continuous improvement strategies using formal, systematic tools for organization-wide strategic deployment.

Without a concrete commitment at the organizational level, programs such as diversity training may end up being band-aids on wounds that run deep.

I believe that the combination of both individual and organizational commitment to change systemic bias in medicine can be quite powerful. One without the other will fail to permanently change the system. The work to true equality – regardless of the intersecting factors of discrimination – starts with a commitment to change. We may all have different opportunities because of the inequality that is apparent in our systems today, but if we unite around the goal of a bias-free, merit-based equality, it gives us the strength we need to overcome challenges that we once thought insurmountable.

Each one of us is a leader in our own right. Speaking up for those with less power or opportunity than us and supporting talent and hard work solidifies medicine as a meritocracy. Even if the magnitude of change that we fight for may not be realized during our time in medical practice, our commitment to eradicate sexism, racism and discrimination will shape the future of medicine.

Just as our children are a legacy that we leave behind, our work in correcting bias in medicine will pave the path for a better future for the doctors of tomorrow. After all, when I think that my young daughter will be affected by what I do or do not do to address the discrimination, there is no better motivation for me to break down every barrier for her success.

Dr. Kanikkannan is a practicing hospitalist and assistant professor of medicine at Albany Medical College in Albany, NY. This article first appeared on The Hospital Leader, the official blog of SHM.

There are many challenges facing modern medicine today. Recent events have highlighted important issues affecting our society as a whole – systemic racism, sexism, and implicit bias. In medicine, we have seen a renewed focus on health equity, health disparities and the implicit systemic bias that affect those who work in the field. It is truly troubling that it has taken the continued loss of black lives to police brutality and a pandemic for this conversation to happen at every level in society.

Systemic bias is present throughout corporate America, and it is no different within the physician workforce. Overall, there has been gradual interest in promoting and teaching diversity. Institutions have been slowly creating policies and administrative positions focused on inclusion and diversity over the last decade. So has diversity training objectively increased representation and advancement of women and minority groups? Do traditionally marginalized groups have better access to health? And are women and people of color (POC) represented equally in leadership positions in medicine?

Clearly, the answers are not straightforward.
 

Diving into the data

A guilty pleasure of mine is to assess how diverse and inclusive an institution is by looking at the wall of pictures recognizing top leadership in hospitals. Despite women accounting for 47.9% of graduates from medical school in 2018-2019, I still see very few women or POC elevated to this level. Of the total women graduates, 22.6% were Asian, 8% were Black and 5.4% were Hispanic.

Being of Indian descent, I am a woman of color (albeit one who may not be as profoundly affected by racism in medicine as my less represented colleagues). It is especially rare for me to see someone I can identify with in the ranks of top leadership. I find encouragement in seeing any woman on any leadership board because to me, it means that there is hope. The literature seems to support this degree of disparity as well. For example, a recent analysis shows that presidential leadership in medical societies are predominantly held by men (82.6% male vs. 17.4% female). Other datasets demonstrate that only 15% of deans and interim deans are women and AAMC’s report shows that women account for only 18% of all department chairs.

Growing up, my parents fueled my interest to pursue medicine. They described it as a noble profession that rewarded true merit and dedication to the cause. However, those that have been traditionally elevated in medicine are men. If merit knows no gender, why does a gender gap exist? If merit is blind to race, why are minorities so poorly represented in the workforce (much less in leadership)? My view of the wall leaves me wondering about the role of both sexism and racism in medicine.

These visual representations of the medical culture reinforce the acceptable norms and values – white and masculine – in medicine. The feminist movement over the last several decades has increased awareness about the need for equality of the sexes. However, it was not until the concept of intersectionality was introduced by Black feminist Professor Kimberle Crenshaw, that feminism become a more inclusive term. Professor Crenshaw’s paper details how every individual has intersecting factors – race, gender, sexual identity, socioeconomic status – that create the sum of their experience be it privilege, oppression, or discrimination.

For example, a White woman has privileges that a woman of color does not. Among non-white women, race and sexual identity are confounding factors – a Black woman, a Black LGBTQ woman, and an Asian woman, for example, will not experience discrimination in the same way. The farther you deviate from the accepted norms and values, the harder it is for you to obtain support and achieve recognition.
 

Addressing the patriarchal structure and systemic bias in medicine

Why do patriarchal structures still exist in medicine? How do we resolve systemic bias? Addressing them in isolation – race or gender or sexual identity – is unlikely to create long-lasting change. For change to occur, organizations and individuals need to be intrinsically motivated. Creating awareness and challenging the status quo is the first step.

Over the last decade, implicit bias training and diversity training have become mandatory in various industries and states. Diversity training has grown to be a multi-billion-dollar industry that corporate America has embraced over the last several years. And yet, research shows that mandating such training may not be the most effective. To get results, organizations need to implement programs that “spark engagement, increase contact between different groups and draw on people’s desire to look good to others.”

Historically, the medical curriculum has not included a discourse on feminist theories and the advancement of women in medicine. Cultural competency training is typically offered on an annual basis once we are in the workforce, but in my experience, it focuses more on our interactions with patients and other health care colleagues, and less with regards to our physician peers and leadership. Is this enough to change deep rooted beliefs and traditions?

We can take our cue from non-medical organizations and consider changing this culture of no culture in medicine – introducing diversity task forces that hold departments accountable for recruiting and promoting women and minorities; employing diversity managers; voluntary training; cross-training to increase contact among different groups and mentoring programs that match senior leadership to women and POC. While some medical institutions have implemented some of these principles, changing century-old traditions will require embracing concepts of organizational change and every available effective tool.
 

Committing to change

Change is especially hard when the target outcome is not accurately quantifiable – even if you can measure attitudes, values, and beliefs, these are subject to reporting bias and tokenism. At the organizational level, change management involves employing a systematic approach to change organizational values, goals, policies, and processes.

Individual change, self-reflection, and personal growth are key components in changing culture. Reflexivity is being aware of your own values, norms, position, and power – an important concept to understand and apply in our everyday interactions. Believing that one’s class, gender, race and sexual orientation are irrelevant to their practice of medicine would not foster the change that we direly need in medicine. Rather, identifying how your own values and professional identity are shaped by your medical training, your organization and the broader cultural context are critically important to developing a greater empathic sense to motivate systemic change.

There has been valuable discussion on bottom-up changes to ensure women and POC have support, encouragement and a pathway to advance in an organization. Some of these include policy and process changes including providing flexible working conditions for women and sponsorship of women and minorities to help them navigate the barriers and microaggressions they encounter at work. While technical (policy) changes form the foundation for any organizational change, it is important to remember that the people side of change – the resistance that you encounter for any change effort in an organization – is equally important to address at the organizational level. A top-down approach is also vital to ensure that change is permanent in an organization and does not end when the individuals responsible for the change leave the organization.

Lewin’s three-stage change management model provides a framework for structural and organizational change in hospital systems. The three-stages of this model are: unfreezing, changing, and refreezing. Unfreezing is the process of determining what needs to change and obtaining leadership support. The actual change process involves getting people on board, empowering them to change and communicating with them frequently. Refreezing cements this change into the organization’s culture by providing support and training to sustain changes. Research has shown that Lewin’s change management model has applicability in the hospital setting.

Industry research in change management methodologies in the business sector has identified sponsorship by CEOs/senior management of an organization and having a structured implementation model for change management as two important factors for ensuring that change efforts are successful and sustainable.

This can be extrapolated to health care organizations – top leadership committed to changing the status quo should solidify organizational commitment by incorporating new attainable and measurable goals into their vision for the organization. Designing a phased implementation of change management methodologies should follow an open discussion to identify an organization’s weaknesses, strengths, capacity, and readiness for change. Lastly, helping busy professionals adapt to change requires innovative and continuous improvement strategies using formal, systematic tools for organization-wide strategic deployment.

Without a concrete commitment at the organizational level, programs such as diversity training may end up being band-aids on wounds that run deep.

I believe that the combination of both individual and organizational commitment to change systemic bias in medicine can be quite powerful. One without the other will fail to permanently change the system. The work to true equality – regardless of the intersecting factors of discrimination – starts with a commitment to change. We may all have different opportunities because of the inequality that is apparent in our systems today, but if we unite around the goal of a bias-free, merit-based equality, it gives us the strength we need to overcome challenges that we once thought insurmountable.

Each one of us is a leader in our own right. Speaking up for those with less power or opportunity than us and supporting talent and hard work solidifies medicine as a meritocracy. Even if the magnitude of change that we fight for may not be realized during our time in medical practice, our commitment to eradicate sexism, racism and discrimination will shape the future of medicine.

Just as our children are a legacy that we leave behind, our work in correcting bias in medicine will pave the path for a better future for the doctors of tomorrow. After all, when I think that my young daughter will be affected by what I do or do not do to address the discrimination, there is no better motivation for me to break down every barrier for her success.

Dr. Kanikkannan is a practicing hospitalist and assistant professor of medicine at Albany Medical College in Albany, NY. This article first appeared on The Hospital Leader, the official blog of SHM.

There are many challenges facing modern medicine today. Recent events have highlighted important issues affecting our society as a whole – systemic racism, sexism, and implicit bias. In medicine, we have seen a renewed focus on health equity, health disparities and the implicit systemic bias that affect those who work in the field. It is truly troubling that it has taken the continued loss of black lives to police brutality and a pandemic for this conversation to happen at every level in society.

Systemic bias is present throughout corporate America, and it is no different within the physician workforce. Overall, there has been gradual interest in promoting and teaching diversity. Institutions have been slowly creating policies and administrative positions focused on inclusion and diversity over the last decade. So has diversity training objectively increased representation and advancement of women and minority groups? Do traditionally marginalized groups have better access to health? And are women and people of color (POC) represented equally in leadership positions in medicine?

Clearly, the answers are not straightforward.
 

Diving into the data

A guilty pleasure of mine is to assess how diverse and inclusive an institution is by looking at the wall of pictures recognizing top leadership in hospitals. Despite women accounting for 47.9% of graduates from medical school in 2018-2019, I still see very few women or POC elevated to this level. Of the total women graduates, 22.6% were Asian, 8% were Black and 5.4% were Hispanic.

Being of Indian descent, I am a woman of color (albeit one who may not be as profoundly affected by racism in medicine as my less represented colleagues). It is especially rare for me to see someone I can identify with in the ranks of top leadership. I find encouragement in seeing any woman on any leadership board because to me, it means that there is hope. The literature seems to support this degree of disparity as well. For example, a recent analysis shows that presidential leadership in medical societies are predominantly held by men (82.6% male vs. 17.4% female). Other datasets demonstrate that only 15% of deans and interim deans are women and AAMC’s report shows that women account for only 18% of all department chairs.

Growing up, my parents fueled my interest to pursue medicine. They described it as a noble profession that rewarded true merit and dedication to the cause. However, those that have been traditionally elevated in medicine are men. If merit knows no gender, why does a gender gap exist? If merit is blind to race, why are minorities so poorly represented in the workforce (much less in leadership)? My view of the wall leaves me wondering about the role of both sexism and racism in medicine.

These visual representations of the medical culture reinforce the acceptable norms and values – white and masculine – in medicine. The feminist movement over the last several decades has increased awareness about the need for equality of the sexes. However, it was not until the concept of intersectionality was introduced by Black feminist Professor Kimberle Crenshaw, that feminism become a more inclusive term. Professor Crenshaw’s paper details how every individual has intersecting factors – race, gender, sexual identity, socioeconomic status – that create the sum of their experience be it privilege, oppression, or discrimination.

For example, a White woman has privileges that a woman of color does not. Among non-white women, race and sexual identity are confounding factors – a Black woman, a Black LGBTQ woman, and an Asian woman, for example, will not experience discrimination in the same way. The farther you deviate from the accepted norms and values, the harder it is for you to obtain support and achieve recognition.
 

Addressing the patriarchal structure and systemic bias in medicine

Why do patriarchal structures still exist in medicine? How do we resolve systemic bias? Addressing them in isolation – race or gender or sexual identity – is unlikely to create long-lasting change. For change to occur, organizations and individuals need to be intrinsically motivated. Creating awareness and challenging the status quo is the first step.

Over the last decade, implicit bias training and diversity training have become mandatory in various industries and states. Diversity training has grown to be a multi-billion-dollar industry that corporate America has embraced over the last several years. And yet, research shows that mandating such training may not be the most effective. To get results, organizations need to implement programs that “spark engagement, increase contact between different groups and draw on people’s desire to look good to others.”

Historically, the medical curriculum has not included a discourse on feminist theories and the advancement of women in medicine. Cultural competency training is typically offered on an annual basis once we are in the workforce, but in my experience, it focuses more on our interactions with patients and other health care colleagues, and less with regards to our physician peers and leadership. Is this enough to change deep rooted beliefs and traditions?

We can take our cue from non-medical organizations and consider changing this culture of no culture in medicine – introducing diversity task forces that hold departments accountable for recruiting and promoting women and minorities; employing diversity managers; voluntary training; cross-training to increase contact among different groups and mentoring programs that match senior leadership to women and POC. While some medical institutions have implemented some of these principles, changing century-old traditions will require embracing concepts of organizational change and every available effective tool.
 

Committing to change

Change is especially hard when the target outcome is not accurately quantifiable – even if you can measure attitudes, values, and beliefs, these are subject to reporting bias and tokenism. At the organizational level, change management involves employing a systematic approach to change organizational values, goals, policies, and processes.

Individual change, self-reflection, and personal growth are key components in changing culture. Reflexivity is being aware of your own values, norms, position, and power – an important concept to understand and apply in our everyday interactions. Believing that one’s class, gender, race and sexual orientation are irrelevant to their practice of medicine would not foster the change that we direly need in medicine. Rather, identifying how your own values and professional identity are shaped by your medical training, your organization and the broader cultural context are critically important to developing a greater empathic sense to motivate systemic change.

There has been valuable discussion on bottom-up changes to ensure women and POC have support, encouragement and a pathway to advance in an organization. Some of these include policy and process changes including providing flexible working conditions for women and sponsorship of women and minorities to help them navigate the barriers and microaggressions they encounter at work. While technical (policy) changes form the foundation for any organizational change, it is important to remember that the people side of change – the resistance that you encounter for any change effort in an organization – is equally important to address at the organizational level. A top-down approach is also vital to ensure that change is permanent in an organization and does not end when the individuals responsible for the change leave the organization.

Lewin’s three-stage change management model provides a framework for structural and organizational change in hospital systems. The three-stages of this model are: unfreezing, changing, and refreezing. Unfreezing is the process of determining what needs to change and obtaining leadership support. The actual change process involves getting people on board, empowering them to change and communicating with them frequently. Refreezing cements this change into the organization’s culture by providing support and training to sustain changes. Research has shown that Lewin’s change management model has applicability in the hospital setting.

Industry research in change management methodologies in the business sector has identified sponsorship by CEOs/senior management of an organization and having a structured implementation model for change management as two important factors for ensuring that change efforts are successful and sustainable.

This can be extrapolated to health care organizations – top leadership committed to changing the status quo should solidify organizational commitment by incorporating new attainable and measurable goals into their vision for the organization. Designing a phased implementation of change management methodologies should follow an open discussion to identify an organization’s weaknesses, strengths, capacity, and readiness for change. Lastly, helping busy professionals adapt to change requires innovative and continuous improvement strategies using formal, systematic tools for organization-wide strategic deployment.

Without a concrete commitment at the organizational level, programs such as diversity training may end up being band-aids on wounds that run deep.

I believe that the combination of both individual and organizational commitment to change systemic bias in medicine can be quite powerful. One without the other will fail to permanently change the system. The work to true equality – regardless of the intersecting factors of discrimination – starts with a commitment to change. We may all have different opportunities because of the inequality that is apparent in our systems today, but if we unite around the goal of a bias-free, merit-based equality, it gives us the strength we need to overcome challenges that we once thought insurmountable.

Each one of us is a leader in our own right. Speaking up for those with less power or opportunity than us and supporting talent and hard work solidifies medicine as a meritocracy. Even if the magnitude of change that we fight for may not be realized during our time in medical practice, our commitment to eradicate sexism, racism and discrimination will shape the future of medicine.

Just as our children are a legacy that we leave behind, our work in correcting bias in medicine will pave the path for a better future for the doctors of tomorrow. After all, when I think that my young daughter will be affected by what I do or do not do to address the discrimination, there is no better motivation for me to break down every barrier for her success.

Dr. Kanikkannan is a practicing hospitalist and assistant professor of medicine at Albany Medical College in Albany, NY. This article first appeared on The Hospital Leader, the official blog of SHM.

Statistics tell the tale of immigrants in the American health care workforce in broad strokes. In an interview, though, one hospitalist shared the particulars of his professional and personal journey since arriving in the United States from India 15 years ago.

Mihir Patel, MD, MPH, FHM, came to the United States in 2005 to complete a Master’s in Public Health. Fifteen years later, he is still waiting for the green card that signifies U.S. permanent residency status. The paperwork for the application, he said, was completed in 2012. Since then, he’s been renewing his H-1B visa every three years, and he has no expectation that anything will change soon.

“If you are from India, which has a significant backlog of green cards – up to 50 years…you just wait forever,” he said. “Many people even die waiting for their green card to arrive.”

Arriving on a student visa, Dr. Patel completed his MPH in 2008 and began an internal medicine residency that same year, holding a J-1 visa for the 3 years of his US residency program.

“Post-residency, I started working in a rural hospital in an underserved area of northeast Tennessee as a hospitalist,” thus completing the 3 years of service in a rural underserved area that’s a requirement for J-1 visa holders, said Dr. Patel. “I loved this rural community hospital so much that I ended up staying there for 6 years. During my work at this rural hospital, I was able to enjoy the autonomy of managing a small ICU, doing both critical care procedures and management of intubated critical patients while working as a hospitalist,” he said. Dr. Patel served as chief of staff at the hospital for two years, and also served on the board of directors for his 400-physician medical group.

“I was a proud member of this rural community – Rogersville,” said Dr. Patel. Although he and his wife, who was completing her hospitalist residency, lived in Johnson City, Tenn., “I did not mind driving 120 miles round trip every day to go to my small-town hospital for 6 years,” he said.

Spending this time in rural Tennessee allowed Dr. Patel to finish the requirements necessary for the Physician National Interest Waiver and submit his application for permanent residency. The waiver, though, doesn’t give him priority status in the waiting list for permanent residency status.

After a stint in northern California to be closer to extended family, the pull of “beautiful northeast Tennesse and the rural community” was too strong, so Dr. Patel and his family moved back to Johnson City in 2018.

Reauthorizing the H1-B visa program

SHM has been advocating to improve the H1-B visa system for years, Dr. Patel said, The Fairness for High Skilled Immigrants Act passed the U.S. House of Representatives with bipartisan support, and the Society is advocating for its passage in the Senate.

The Fairness for High-Skilled Immigrants Act (S. 386) simplifies the employment-based immigration system by removing per-country caps, converting the employment-based immigration system into a “first-come, first serve” system that does not discriminate on country of origin. The act will also help alleviate the decades-long green card and permanent residency application backlogs.

Dr. Patel emphasized the importance of action by Congress to reauthorize the physician visa waiver program and expediting physician permanent residency. “This is a crisis and we are all physicians who are ready to serve, regardless of our country of origin. Please let us help this great nation by giving us freedom from visa restrictions and providing security for our families.

“During wartime, all frontline soldiers are naturalized and given citizenship by presidential mandate; this is more than war and we are not asking for citizenship – but at least give us a green card which we have already satisfied all requirements for. If not now, then when?” he asked.

Statistics tell the tale of immigrants in the American health care workforce in broad strokes. In an interview, though, one hospitalist shared the particulars of his professional and personal journey since arriving in the United States from India 15 years ago.

Mihir Patel, MD, MPH, FHM, came to the United States in 2005 to complete a Master’s in Public Health. Fifteen years later, he is still waiting for the green card that signifies U.S. permanent residency status. The paperwork for the application, he said, was completed in 2012. Since then, he’s been renewing his H-1B visa every three years, and he has no expectation that anything will change soon.

“If you are from India, which has a significant backlog of green cards – up to 50 years…you just wait forever,” he said. “Many people even die waiting for their green card to arrive.”

Arriving on a student visa, Dr. Patel completed his MPH in 2008 and began an internal medicine residency that same year, holding a J-1 visa for the 3 years of his US residency program.

“Post-residency, I started working in a rural hospital in an underserved area of northeast Tennessee as a hospitalist,” thus completing the 3 years of service in a rural underserved area that’s a requirement for J-1 visa holders, said Dr. Patel. “I loved this rural community hospital so much that I ended up staying there for 6 years. During my work at this rural hospital, I was able to enjoy the autonomy of managing a small ICU, doing both critical care procedures and management of intubated critical patients while working as a hospitalist,” he said. Dr. Patel served as chief of staff at the hospital for two years, and also served on the board of directors for his 400-physician medical group.

“I was a proud member of this rural community – Rogersville,” said Dr. Patel. Although he and his wife, who was completing her hospitalist residency, lived in Johnson City, Tenn., “I did not mind driving 120 miles round trip every day to go to my small-town hospital for 6 years,” he said.

Spending this time in rural Tennessee allowed Dr. Patel to finish the requirements necessary for the Physician National Interest Waiver and submit his application for permanent residency. The waiver, though, doesn’t give him priority status in the waiting list for permanent residency status.

After a stint in northern California to be closer to extended family, the pull of “beautiful northeast Tennesse and the rural community” was too strong, so Dr. Patel and his family moved back to Johnson City in 2018.

Reauthorizing the H1-B visa program

SHM has been advocating to improve the H1-B visa system for years, Dr. Patel said, The Fairness for High Skilled Immigrants Act passed the U.S. House of Representatives with bipartisan support, and the Society is advocating for its passage in the Senate.

The Fairness for High-Skilled Immigrants Act (S. 386) simplifies the employment-based immigration system by removing per-country caps, converting the employment-based immigration system into a “first-come, first serve” system that does not discriminate on country of origin. The act will also help alleviate the decades-long green card and permanent residency application backlogs.

Dr. Patel emphasized the importance of action by Congress to reauthorize the physician visa waiver program and expediting physician permanent residency. “This is a crisis and we are all physicians who are ready to serve, regardless of our country of origin. Please let us help this great nation by giving us freedom from visa restrictions and providing security for our families.

“During wartime, all frontline soldiers are naturalized and given citizenship by presidential mandate; this is more than war and we are not asking for citizenship – but at least give us a green card which we have already satisfied all requirements for. If not now, then when?” he asked.

Statistics tell the tale of immigrants in the American health care workforce in broad strokes. In an interview, though, one hospitalist shared the particulars of his professional and personal journey since arriving in the United States from India 15 years ago.

Mihir Patel, MD, MPH, FHM, came to the United States in 2005 to complete a Master’s in Public Health. Fifteen years later, he is still waiting for the green card that signifies U.S. permanent residency status. The paperwork for the application, he said, was completed in 2012. Since then, he’s been renewing his H-1B visa every three years, and he has no expectation that anything will change soon.

“If you are from India, which has a significant backlog of green cards – up to 50 years…you just wait forever,” he said. “Many people even die waiting for their green card to arrive.”

Arriving on a student visa, Dr. Patel completed his MPH in 2008 and began an internal medicine residency that same year, holding a J-1 visa for the 3 years of his US residency program.

“Post-residency, I started working in a rural hospital in an underserved area of northeast Tennessee as a hospitalist,” thus completing the 3 years of service in a rural underserved area that’s a requirement for J-1 visa holders, said Dr. Patel. “I loved this rural community hospital so much that I ended up staying there for 6 years. During my work at this rural hospital, I was able to enjoy the autonomy of managing a small ICU, doing both critical care procedures and management of intubated critical patients while working as a hospitalist,” he said. Dr. Patel served as chief of staff at the hospital for two years, and also served on the board of directors for his 400-physician medical group.

“I was a proud member of this rural community – Rogersville,” said Dr. Patel. Although he and his wife, who was completing her hospitalist residency, lived in Johnson City, Tenn., “I did not mind driving 120 miles round trip every day to go to my small-town hospital for 6 years,” he said.

Spending this time in rural Tennessee allowed Dr. Patel to finish the requirements necessary for the Physician National Interest Waiver and submit his application for permanent residency. The waiver, though, doesn’t give him priority status in the waiting list for permanent residency status.

After a stint in northern California to be closer to extended family, the pull of “beautiful northeast Tennesse and the rural community” was too strong, so Dr. Patel and his family moved back to Johnson City in 2018.

Reauthorizing the H1-B visa program

SHM has been advocating to improve the H1-B visa system for years, Dr. Patel said, The Fairness for High Skilled Immigrants Act passed the U.S. House of Representatives with bipartisan support, and the Society is advocating for its passage in the Senate.

The Fairness for High-Skilled Immigrants Act (S. 386) simplifies the employment-based immigration system by removing per-country caps, converting the employment-based immigration system into a “first-come, first serve” system that does not discriminate on country of origin. The act will also help alleviate the decades-long green card and permanent residency application backlogs.

Dr. Patel emphasized the importance of action by Congress to reauthorize the physician visa waiver program and expediting physician permanent residency. “This is a crisis and we are all physicians who are ready to serve, regardless of our country of origin. Please let us help this great nation by giving us freedom from visa restrictions and providing security for our families.

“During wartime, all frontline soldiers are naturalized and given citizenship by presidential mandate; this is more than war and we are not asking for citizenship – but at least give us a green card which we have already satisfied all requirements for. If not now, then when?” he asked.

The year 2020 has brought the COVID-19 pandemic and civil unrest and protests, which have resulted in unprecedented health care challenges to hospitals and clinics. The daunting prospect of a fall influenza season has hospital staff and administrators looking ahead to still greater challenges.

This year of crisis has put even greater emphasis on leadership in hospitals, as patients, clinicians, and staff look for direction in the face of uncertainty and stress. But hospital leaders often arrive at their positions unprepared for their roles, according to Leonard Marcus, PhD, director of the Program for Health Care Negotiation and Conflict Resolution at Harvard T.H. Chan School of Public Health, Boston.

“Many times what happens in medicine is that someone with the greatest technical skills or greatest clinical skills emerges to be leader of a department, or a group, or a hospital, without having really paid attention to how they can build their leadership skills,” Dr. Marcus said during the 2020 Society of Hospital Medicine Leadership Virtual Seminar, held online Sept. 16-17.

Over 2 days, Dr. Marcus discussed the complex environments faced by hospital leaders, and some of the tools and strategies that can be used to maintain calm, problem-solve, and chart a course ahead.

He emphasized that hospitals and medical systems are complex, nonlinear organizations, which could be swept up by change in the form of mergers, financial policies, patient surges due to local emergencies, or pandemics.

“Complexity has to be central to how you think about leadership. If you think you can control everything, that doesn’t work that well,” said Dr. Marcus.

Most think of leadership as hierarchical, with a boss on top and underlings below, though this is starting to change. Dr. Marcus suggested a different view. Instead of just “leading down” to those who report to them, leaders should consider “leading up” to their own bosses or oversight committees, and across to other departments or even beyond to interlinked organizations such as nursing homes.

“Being able to build that connectivity not only within your hospital, but beyond your hospital, lets you see the chain that goes through the experience of any patient. You are looking at the problem from a much wider lens. We call this meta-leadership,” Dr. Marcus said.

A key focus of meta-leadership is to create a culture where individuals are working together to help one another succeed. Leadership in hospitals is often dominated by egos, with individual leaders battling one another in a win-lose effort, and this gets in the way of incorporating different perspectives into problem-solving.

Dr. Marcus used an example from previous seminars in which he instructed participants to arm wrestle the person sitting next to them. The goal was to attain as many pins as possible in 30 seconds. About half would fight as hard as they could, and achieve a few victories. The other half worked cooperatively, letting one person win, then the other, so that they could have 30 or 40 wins each. Dr. Marcus told the story of a young nurse who was paired up with a much stronger surgeon. She let him win twice, and when he asked her why she wasn’t resisting, she took his arm and placed it in a winning position, then a losing position, and then a winning position again, and he instantly understood that the cooperative approach could be more effective. Why didn’t she just tell him? She told Dr. Marcus that she knew he wouldn’t take instruction, so she let him win and then demonstrated an alternative. “We nurses learned how to do that a long time ago,” she told Dr. Marcus.

The idea is collaborative problem-solving. “How do you orient people looking to you for leadership so that we’re in this together and we can accomplish a whole lot more in 30 seconds if we’re working together instead of always battling one another? If we’re always battling one another, we’re putting all of our effort into the contest,” said Dr. Marcus. This sort of approach is all the more important when facing the complexity experienced by hospital systems, especially during crises such as COVID-19.

A critical element of meta-leadership is emotional intelligence, which includes elements such as self-awareness, self-regulation, empathy, determining motivation of yourself and others, and the social skills to portray yourself as caring, open, and interested.

Emotional intelligence also can help recognize when you’ve entered survival mode in reaction to a crisis or incident, or something as simple as losing your car keys – what Dr. Marcus terms “going to the basement.” Responses revolve around freeze, fight, or flight. It’s helpful in the wake of a car accident, but not when trying to make managerial decisions or respond to a complex situation. It’s vital for leaders to quickly get themselves out of the basement, said Dr. Marcus, and that they help other members of the team get out as well.

He recommended protocols designed in advance, both to recognize when you’re in the basement, and to lift yourself out. Dr. Marcus uses a trigger script, telling himself “I can do this,” and then when he’s working with other people, “we can do this.” He also speaks slowly, measuring every word. Whatever you do, “it has to be a pivot you do to get yourself out of the basement,” he said. It can be helpful to predict the kinds of situations that send you “to the basement” to help recognize it when it has happened.

It’s very important not to lead, negotiate, or make important decisions while in the basement, according to Dr. Marcus. If one thinks about some of the things they’ve said to others while under duress, they are often some of the statements they regret most.
 

Practical leadership skills

On the second day of the Leadership Seminar, Dr. Marcus moved his focus to using leadership skills and techniques. One important technique is to incorporate multiple perspectives. He gave the example of an opaque cube with a cone inside it, with a window on the side and one on top. Viewers from the side see the cone in profile, and see it as a triangle. Viewers from the top see an aerial perspective that looks like the circular base of the cone. The two groups could argue about what’s inside the cube, but they can only identify the object if they work together.

“When dealing with complex reality, you oftentimes find there are different people with different perspectives on a problem. They may have different experiences of what the problem is, and what often happens is that people get into an adversarial fight. Looking at the problem from different perspectives actually allows a much richer and more comprehensive view,” said Dr. Marcus.

The metaphor comes from a study of the tragic events at the Twin Towers in Manhattan on Sept. 11, 2001. The New York Fire Department had a command center at the base of the building, while the police had a helicopter flying around the buildings. The helicopter could see the steel girders beginning to melt and predicted a collapse, and therefore ordered their personnel out of the buildings. But they were unable to convey that information to the firefighters, who continued to send personnel into the buildings. In all, 343 firefighters lost their lives. The police force lost 32.

To best understand a problem, a key element is the “unknown knowns.” That is, information that is available, that someone has, but is unknown to you. It takes some imagination to conceive of what “unknown knowns” might be out there, but it’s worth the effort to identify possible knowledge sources. It’s vital to seek out this information, because a common leadership mistake is to assume you know something when you really don’t.

“In many ways what you’re doing is looking for obstacles. It could be you don’t have access to the information, that it’s beyond some sort of curtain you need to overcome, or it could be people in your own department who have the information and they’re not sharing it with you,” Dr. Marcus said.

He outlined a tool called the POP-DOC loop, which is a 6-step exercise designed to analyze problems and implement solutions. Step 1 is Perceiving the situation, determining knowns and unknowns, and incorporating multiple perspectives, emotions, and politics. Step 2 is to Orient oneself: examine patterns and how they may replicate themselves as long as conditions don’t change. For example, during COVID-19, physicians have begun to learn how the virus transmits and how it affects the immune system. Step 3, based on those patterns is to make Predictions. With COVID-19, it’s predictable that people who assemble without wearing masks are vulnerable to transmission. Step 4 is to use the predictions to begin to make Decisions. Step 5 is to begin Operationalizing those decisions, and step 6 is to Communicate those decisions effectively.

Dr. Marcus emphasized that POP-DOC is not a one-time exercise. Once decisions have been made and implemented, if they aren’t having the planned effect, it’s important to incorporate the results of those actions and start right back at the beginning of the POP-DOC loop.

“The POP side of the loop is perceiving, analysis. You get out of the basement and understand the situation that surrounds you. On the DOC side, you lead down, lead up, lead across and lead beyond. You’re bringing people into the action to get things done,” Dr. Marcus said.

Another tool Dr. Marcus described, aimed at problem-solving and negotiation, is the “Walk in the Woods.” The idea is to bring two parties together to help each other succeed. The first step is Self-Interest, where both parties articulate their objectives, perspectives, and fears. The second step, Enlarged Interests, requires each party to list their points of agreement, and only then should they focus on and list their points of disagreement. During conflict, people tend to focus on their disagreements. The parties often find that they agree on more than they realize, and this can frame the disagreements as more manageable. The third step, Enlightened Interest, is a free thinking period where both parties come up with potential solutions that had not been previously considered. In step 4, Aligned Interests, the parties discuss some of those ideas that can be explored further.

The Walk in the Woods is applicable to a wide range of situations, and negotiation is central to being a leader. “Being a clinician is all about negotiating – with patients, family members, with other clinicians, with the institution,” Dr. Marcus said. “We all want the patient to have the best possible care, and in the course of those conversations if we can better understand people, have empathy, and if there are new ideas or ways we can individualize our care, let’s do it, and then at the end of the day combine our motivations so that we’re providing the best possible care.”

In the end, meta-leadership is about creating a culture where individuals strive to help each other succeed, said Dr. Marcus. “That’s the essence: involving people, making them part of the solution, and if it’s a solution they’ve created together, everyone wants to make that solution a success.”

For more information, see the book “You’re It,” coauthored by Dr. Marcus, and available on Amazon for $16.99 in hardback, or $3.99 in Kindle format.

The year 2020 has brought the COVID-19 pandemic and civil unrest and protests, which have resulted in unprecedented health care challenges to hospitals and clinics. The daunting prospect of a fall influenza season has hospital staff and administrators looking ahead to still greater challenges.

This year of crisis has put even greater emphasis on leadership in hospitals, as patients, clinicians, and staff look for direction in the face of uncertainty and stress. But hospital leaders often arrive at their positions unprepared for their roles, according to Leonard Marcus, PhD, director of the Program for Health Care Negotiation and Conflict Resolution at Harvard T.H. Chan School of Public Health, Boston.

“Many times what happens in medicine is that someone with the greatest technical skills or greatest clinical skills emerges to be leader of a department, or a group, or a hospital, without having really paid attention to how they can build their leadership skills,” Dr. Marcus said during the 2020 Society of Hospital Medicine Leadership Virtual Seminar, held online Sept. 16-17.

Over 2 days, Dr. Marcus discussed the complex environments faced by hospital leaders, and some of the tools and strategies that can be used to maintain calm, problem-solve, and chart a course ahead.

He emphasized that hospitals and medical systems are complex, nonlinear organizations, which could be swept up by change in the form of mergers, financial policies, patient surges due to local emergencies, or pandemics.

“Complexity has to be central to how you think about leadership. If you think you can control everything, that doesn’t work that well,” said Dr. Marcus.

Most think of leadership as hierarchical, with a boss on top and underlings below, though this is starting to change. Dr. Marcus suggested a different view. Instead of just “leading down” to those who report to them, leaders should consider “leading up” to their own bosses or oversight committees, and across to other departments or even beyond to interlinked organizations such as nursing homes.

“Being able to build that connectivity not only within your hospital, but beyond your hospital, lets you see the chain that goes through the experience of any patient. You are looking at the problem from a much wider lens. We call this meta-leadership,” Dr. Marcus said.

A key focus of meta-leadership is to create a culture where individuals are working together to help one another succeed. Leadership in hospitals is often dominated by egos, with individual leaders battling one another in a win-lose effort, and this gets in the way of incorporating different perspectives into problem-solving.

Dr. Marcus used an example from previous seminars in which he instructed participants to arm wrestle the person sitting next to them. The goal was to attain as many pins as possible in 30 seconds. About half would fight as hard as they could, and achieve a few victories. The other half worked cooperatively, letting one person win, then the other, so that they could have 30 or 40 wins each. Dr. Marcus told the story of a young nurse who was paired up with a much stronger surgeon. She let him win twice, and when he asked her why she wasn’t resisting, she took his arm and placed it in a winning position, then a losing position, and then a winning position again, and he instantly understood that the cooperative approach could be more effective. Why didn’t she just tell him? She told Dr. Marcus that she knew he wouldn’t take instruction, so she let him win and then demonstrated an alternative. “We nurses learned how to do that a long time ago,” she told Dr. Marcus.

The idea is collaborative problem-solving. “How do you orient people looking to you for leadership so that we’re in this together and we can accomplish a whole lot more in 30 seconds if we’re working together instead of always battling one another? If we’re always battling one another, we’re putting all of our effort into the contest,” said Dr. Marcus. This sort of approach is all the more important when facing the complexity experienced by hospital systems, especially during crises such as COVID-19.

A critical element of meta-leadership is emotional intelligence, which includes elements such as self-awareness, self-regulation, empathy, determining motivation of yourself and others, and the social skills to portray yourself as caring, open, and interested.

Emotional intelligence also can help recognize when you’ve entered survival mode in reaction to a crisis or incident, or something as simple as losing your car keys – what Dr. Marcus terms “going to the basement.” Responses revolve around freeze, fight, or flight. It’s helpful in the wake of a car accident, but not when trying to make managerial decisions or respond to a complex situation. It’s vital for leaders to quickly get themselves out of the basement, said Dr. Marcus, and that they help other members of the team get out as well.

He recommended protocols designed in advance, both to recognize when you’re in the basement, and to lift yourself out. Dr. Marcus uses a trigger script, telling himself “I can do this,” and then when he’s working with other people, “we can do this.” He also speaks slowly, measuring every word. Whatever you do, “it has to be a pivot you do to get yourself out of the basement,” he said. It can be helpful to predict the kinds of situations that send you “to the basement” to help recognize it when it has happened.

It’s very important not to lead, negotiate, or make important decisions while in the basement, according to Dr. Marcus. If one thinks about some of the things they’ve said to others while under duress, they are often some of the statements they regret most.
 

Practical leadership skills

On the second day of the Leadership Seminar, Dr. Marcus moved his focus to using leadership skills and techniques. One important technique is to incorporate multiple perspectives. He gave the example of an opaque cube with a cone inside it, with a window on the side and one on top. Viewers from the side see the cone in profile, and see it as a triangle. Viewers from the top see an aerial perspective that looks like the circular base of the cone. The two groups could argue about what’s inside the cube, but they can only identify the object if they work together.

“When dealing with complex reality, you oftentimes find there are different people with different perspectives on a problem. They may have different experiences of what the problem is, and what often happens is that people get into an adversarial fight. Looking at the problem from different perspectives actually allows a much richer and more comprehensive view,” said Dr. Marcus.

The metaphor comes from a study of the tragic events at the Twin Towers in Manhattan on Sept. 11, 2001. The New York Fire Department had a command center at the base of the building, while the police had a helicopter flying around the buildings. The helicopter could see the steel girders beginning to melt and predicted a collapse, and therefore ordered their personnel out of the buildings. But they were unable to convey that information to the firefighters, who continued to send personnel into the buildings. In all, 343 firefighters lost their lives. The police force lost 32.

To best understand a problem, a key element is the “unknown knowns.” That is, information that is available, that someone has, but is unknown to you. It takes some imagination to conceive of what “unknown knowns” might be out there, but it’s worth the effort to identify possible knowledge sources. It’s vital to seek out this information, because a common leadership mistake is to assume you know something when you really don’t.

“In many ways what you’re doing is looking for obstacles. It could be you don’t have access to the information, that it’s beyond some sort of curtain you need to overcome, or it could be people in your own department who have the information and they’re not sharing it with you,” Dr. Marcus said.

He outlined a tool called the POP-DOC loop, which is a 6-step exercise designed to analyze problems and implement solutions. Step 1 is Perceiving the situation, determining knowns and unknowns, and incorporating multiple perspectives, emotions, and politics. Step 2 is to Orient oneself: examine patterns and how they may replicate themselves as long as conditions don’t change. For example, during COVID-19, physicians have begun to learn how the virus transmits and how it affects the immune system. Step 3, based on those patterns is to make Predictions. With COVID-19, it’s predictable that people who assemble without wearing masks are vulnerable to transmission. Step 4 is to use the predictions to begin to make Decisions. Step 5 is to begin Operationalizing those decisions, and step 6 is to Communicate those decisions effectively.

Dr. Marcus emphasized that POP-DOC is not a one-time exercise. Once decisions have been made and implemented, if they aren’t having the planned effect, it’s important to incorporate the results of those actions and start right back at the beginning of the POP-DOC loop.

“The POP side of the loop is perceiving, analysis. You get out of the basement and understand the situation that surrounds you. On the DOC side, you lead down, lead up, lead across and lead beyond. You’re bringing people into the action to get things done,” Dr. Marcus said.

Another tool Dr. Marcus described, aimed at problem-solving and negotiation, is the “Walk in the Woods.” The idea is to bring two parties together to help each other succeed. The first step is Self-Interest, where both parties articulate their objectives, perspectives, and fears. The second step, Enlarged Interests, requires each party to list their points of agreement, and only then should they focus on and list their points of disagreement. During conflict, people tend to focus on their disagreements. The parties often find that they agree on more than they realize, and this can frame the disagreements as more manageable. The third step, Enlightened Interest, is a free thinking period where both parties come up with potential solutions that had not been previously considered. In step 4, Aligned Interests, the parties discuss some of those ideas that can be explored further.

The Walk in the Woods is applicable to a wide range of situations, and negotiation is central to being a leader. “Being a clinician is all about negotiating – with patients, family members, with other clinicians, with the institution,” Dr. Marcus said. “We all want the patient to have the best possible care, and in the course of those conversations if we can better understand people, have empathy, and if there are new ideas or ways we can individualize our care, let’s do it, and then at the end of the day combine our motivations so that we’re providing the best possible care.”

In the end, meta-leadership is about creating a culture where individuals strive to help each other succeed, said Dr. Marcus. “That’s the essence: involving people, making them part of the solution, and if it’s a solution they’ve created together, everyone wants to make that solution a success.”

For more information, see the book “You’re It,” coauthored by Dr. Marcus, and available on Amazon for $16.99 in hardback, or $3.99 in Kindle format.

The year 2020 has brought the COVID-19 pandemic and civil unrest and protests, which have resulted in unprecedented health care challenges to hospitals and clinics. The daunting prospect of a fall influenza season has hospital staff and administrators looking ahead to still greater challenges.

This year of crisis has put even greater emphasis on leadership in hospitals, as patients, clinicians, and staff look for direction in the face of uncertainty and stress. But hospital leaders often arrive at their positions unprepared for their roles, according to Leonard Marcus, PhD, director of the Program for Health Care Negotiation and Conflict Resolution at Harvard T.H. Chan School of Public Health, Boston.

“Many times what happens in medicine is that someone with the greatest technical skills or greatest clinical skills emerges to be leader of a department, or a group, or a hospital, without having really paid attention to how they can build their leadership skills,” Dr. Marcus said during the 2020 Society of Hospital Medicine Leadership Virtual Seminar, held online Sept. 16-17.

Over 2 days, Dr. Marcus discussed the complex environments faced by hospital leaders, and some of the tools and strategies that can be used to maintain calm, problem-solve, and chart a course ahead.

He emphasized that hospitals and medical systems are complex, nonlinear organizations, which could be swept up by change in the form of mergers, financial policies, patient surges due to local emergencies, or pandemics.

“Complexity has to be central to how you think about leadership. If you think you can control everything, that doesn’t work that well,” said Dr. Marcus.

Most think of leadership as hierarchical, with a boss on top and underlings below, though this is starting to change. Dr. Marcus suggested a different view. Instead of just “leading down” to those who report to them, leaders should consider “leading up” to their own bosses or oversight committees, and across to other departments or even beyond to interlinked organizations such as nursing homes.

“Being able to build that connectivity not only within your hospital, but beyond your hospital, lets you see the chain that goes through the experience of any patient. You are looking at the problem from a much wider lens. We call this meta-leadership,” Dr. Marcus said.

A key focus of meta-leadership is to create a culture where individuals are working together to help one another succeed. Leadership in hospitals is often dominated by egos, with individual leaders battling one another in a win-lose effort, and this gets in the way of incorporating different perspectives into problem-solving.

Dr. Marcus used an example from previous seminars in which he instructed participants to arm wrestle the person sitting next to them. The goal was to attain as many pins as possible in 30 seconds. About half would fight as hard as they could, and achieve a few victories. The other half worked cooperatively, letting one person win, then the other, so that they could have 30 or 40 wins each. Dr. Marcus told the story of a young nurse who was paired up with a much stronger surgeon. She let him win twice, and when he asked her why she wasn’t resisting, she took his arm and placed it in a winning position, then a losing position, and then a winning position again, and he instantly understood that the cooperative approach could be more effective. Why didn’t she just tell him? She told Dr. Marcus that she knew he wouldn’t take instruction, so she let him win and then demonstrated an alternative. “We nurses learned how to do that a long time ago,” she told Dr. Marcus.

The idea is collaborative problem-solving. “How do you orient people looking to you for leadership so that we’re in this together and we can accomplish a whole lot more in 30 seconds if we’re working together instead of always battling one another? If we’re always battling one another, we’re putting all of our effort into the contest,” said Dr. Marcus. This sort of approach is all the more important when facing the complexity experienced by hospital systems, especially during crises such as COVID-19.

A critical element of meta-leadership is emotional intelligence, which includes elements such as self-awareness, self-regulation, empathy, determining motivation of yourself and others, and the social skills to portray yourself as caring, open, and interested.

Emotional intelligence also can help recognize when you’ve entered survival mode in reaction to a crisis or incident, or something as simple as losing your car keys – what Dr. Marcus terms “going to the basement.” Responses revolve around freeze, fight, or flight. It’s helpful in the wake of a car accident, but not when trying to make managerial decisions or respond to a complex situation. It’s vital for leaders to quickly get themselves out of the basement, said Dr. Marcus, and that they help other members of the team get out as well.

He recommended protocols designed in advance, both to recognize when you’re in the basement, and to lift yourself out. Dr. Marcus uses a trigger script, telling himself “I can do this,” and then when he’s working with other people, “we can do this.” He also speaks slowly, measuring every word. Whatever you do, “it has to be a pivot you do to get yourself out of the basement,” he said. It can be helpful to predict the kinds of situations that send you “to the basement” to help recognize it when it has happened.

It’s very important not to lead, negotiate, or make important decisions while in the basement, according to Dr. Marcus. If one thinks about some of the things they’ve said to others while under duress, they are often some of the statements they regret most.
 

Practical leadership skills

On the second day of the Leadership Seminar, Dr. Marcus moved his focus to using leadership skills and techniques. One important technique is to incorporate multiple perspectives. He gave the example of an opaque cube with a cone inside it, with a window on the side and one on top. Viewers from the side see the cone in profile, and see it as a triangle. Viewers from the top see an aerial perspective that looks like the circular base of the cone. The two groups could argue about what’s inside the cube, but they can only identify the object if they work together.

“When dealing with complex reality, you oftentimes find there are different people with different perspectives on a problem. They may have different experiences of what the problem is, and what often happens is that people get into an adversarial fight. Looking at the problem from different perspectives actually allows a much richer and more comprehensive view,” said Dr. Marcus.

The metaphor comes from a study of the tragic events at the Twin Towers in Manhattan on Sept. 11, 2001. The New York Fire Department had a command center at the base of the building, while the police had a helicopter flying around the buildings. The helicopter could see the steel girders beginning to melt and predicted a collapse, and therefore ordered their personnel out of the buildings. But they were unable to convey that information to the firefighters, who continued to send personnel into the buildings. In all, 343 firefighters lost their lives. The police force lost 32.

To best understand a problem, a key element is the “unknown knowns.” That is, information that is available, that someone has, but is unknown to you. It takes some imagination to conceive of what “unknown knowns” might be out there, but it’s worth the effort to identify possible knowledge sources. It’s vital to seek out this information, because a common leadership mistake is to assume you know something when you really don’t.

“In many ways what you’re doing is looking for obstacles. It could be you don’t have access to the information, that it’s beyond some sort of curtain you need to overcome, or it could be people in your own department who have the information and they’re not sharing it with you,” Dr. Marcus said.

He outlined a tool called the POP-DOC loop, which is a 6-step exercise designed to analyze problems and implement solutions. Step 1 is Perceiving the situation, determining knowns and unknowns, and incorporating multiple perspectives, emotions, and politics. Step 2 is to Orient oneself: examine patterns and how they may replicate themselves as long as conditions don’t change. For example, during COVID-19, physicians have begun to learn how the virus transmits and how it affects the immune system. Step 3, based on those patterns is to make Predictions. With COVID-19, it’s predictable that people who assemble without wearing masks are vulnerable to transmission. Step 4 is to use the predictions to begin to make Decisions. Step 5 is to begin Operationalizing those decisions, and step 6 is to Communicate those decisions effectively.

Dr. Marcus emphasized that POP-DOC is not a one-time exercise. Once decisions have been made and implemented, if they aren’t having the planned effect, it’s important to incorporate the results of those actions and start right back at the beginning of the POP-DOC loop.

“The POP side of the loop is perceiving, analysis. You get out of the basement and understand the situation that surrounds you. On the DOC side, you lead down, lead up, lead across and lead beyond. You’re bringing people into the action to get things done,” Dr. Marcus said.

Another tool Dr. Marcus described, aimed at problem-solving and negotiation, is the “Walk in the Woods.” The idea is to bring two parties together to help each other succeed. The first step is Self-Interest, where both parties articulate their objectives, perspectives, and fears. The second step, Enlarged Interests, requires each party to list their points of agreement, and only then should they focus on and list their points of disagreement. During conflict, people tend to focus on their disagreements. The parties often find that they agree on more than they realize, and this can frame the disagreements as more manageable. The third step, Enlightened Interest, is a free thinking period where both parties come up with potential solutions that had not been previously considered. In step 4, Aligned Interests, the parties discuss some of those ideas that can be explored further.

The Walk in the Woods is applicable to a wide range of situations, and negotiation is central to being a leader. “Being a clinician is all about negotiating – with patients, family members, with other clinicians, with the institution,” Dr. Marcus said. “We all want the patient to have the best possible care, and in the course of those conversations if we can better understand people, have empathy, and if there are new ideas or ways we can individualize our care, let’s do it, and then at the end of the day combine our motivations so that we’re providing the best possible care.”

In the end, meta-leadership is about creating a culture where individuals strive to help each other succeed, said Dr. Marcus. “That’s the essence: involving people, making them part of the solution, and if it’s a solution they’ve created together, everyone wants to make that solution a success.”

For more information, see the book “You’re It,” coauthored by Dr. Marcus, and available on Amazon for $16.99 in hardback, or $3.99 in Kindle format.

It was 6 a.m. on a rainy, cold Pacific Northwest morning as I walked from my apartment to the hospital, dodging puddles and dreaming of the mediocre-yet-hot physician-lounge coffee. Another long day full of clinical and administrative tasks awaited me.

I was 6 months’ pregnant with our first child and working my sixth 12-hour shift in a row. We had recently lost our medical director, and the C-suite had offered me the role. The day ahead seemed like an enormous mountain to climb.

I felt tired and more than a little overwhelmed. But I whispered to myself: “Today is going to be a fantastic day. I will not fail my team. I will not fail my patients!”
 

Physician leadership starts with a decision

The timing of this call to leadership had not been ideal. There’s probably never a perfect time to step into a medical director role. And my situation was no exception.

In addition to the baby on the way, my husband was traveling a lot for work. Also, the job of a medical director seemed a little daunting – especially to a young physician leading a team for the first time.

But I knew that leadership was my calling. While I didn’t yet have decades of experience, I had been selected as the chief resident in internal medicine, completed a nephrology fellowship, and mentored several medical students and residents along my career path.

I also knew that I was passionate about supporting my patients and hospitalist team. I’d previously served as associate medical director in charge of quality, readmission reduction, and patient experience. Having achieved the highest patient satisfaction scores on the team for 2 consecutive years, I was specially tasked to improve our team’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

These experiences taught me that coaching with positive reinforcement was in my blood. This gave me the courage to face my tallest mountain yet.
 

No one climbs a mountain alone

I also stepped into my new physician leadership role with amazing support. Our outgoing medical director had recommended me, and my entire team was rooting for me. My spouse was 100% behind the idea.

Courtesy Dr. Swati Mehta

What’s more, I had received amazing feedback from patients throughout my 3 years at the hospital. I had papered an entire office wall with their thank-you notes. I even had a quilt that an 85-year-old patient’s wife made to thank me for my compassionate care.

As I weighed my decision, I realized that I had a higher calling to be a true advocate for my patients. I loved what I did. Each day, I resolved to bring my best and most authentic self for them – no matter how drained I felt.

My team and patients needed me now, not at some more convenient time down the road. A medical director job was the natural next step for me. And so, I resolved to climb the mountain.
 

Climbing through storms

Stepping into a medical director job forced me to grow into a completely new person. So maybe starting that role during pregnancy was a great metaphor!

Each day, there was immense pressure to perform, to deliver quality outcomes, and to simultaneously meet expectations of the C-suite as well as my hospitalist team. There was no room for failure, because too much was at stake.

Looking back today, I wouldn’t trade the experience for anything. The medical director role was one of the most gratifying experiences in my life, and I am truly thankful for it.

A leader’s role truly boils down to working tirelessly to collaborate with different care teams. It’s important to care not only about our patients but also about our fellow hospitalists. We can do this by truly leading by example – be it picking up extra shifts, covering holidays so team members can be with family, or coming in at 10 p.m. to round with your night team.

I was also able to bring a unique perspective to the hospital C-suite meetings as a woman, an immigrant, and a true “mama bear” – not only of my infant son but also of my team.

Courtesy Dr. Swati Mehta

My first year as a medical director required more commitment and heart than I could have imagined. But all this hard work paid off when our hospitalist group received the coveted Best Team Award for most improved quality outcomes, financial performance, and patient experience.
 

The summit is the beginning

My first medical director job fueled my passion for patient satisfaction even further. I now serve as the director of patient experience for the more than 4,200 clinicians at Vituity. Together we care for more than 6.5 million lives a year across the country.

In 2019, I coached 300 physicians and hospital leaders on communication, collaboration, and service recovery skills, leading to significant improvement in their HCAHPS scores. I was delighted to receive the Vituity Distinguished Service Award for my contributions. It’s such an honor to be instrumental in impacting patient care at a larger scale.

This year, I was invited to serve as vice chair of the Society for Hospital Medicine’s patient experience committee and to join the executive board of the SHM San Francisco chapter. Together, we have created a COVID-19 patient communication resource and reached out to our hospitalists to provide them with a space to share their stories during this pandemic. I am so excited to share my knowledge and passion with clinicians across the country given the wide reach of Vituity & SHM!

Many hospitalists shy away from leadership roles. The mountain is tough to scale, but the view from the top is worth it. The key is to start, even if you don’t feel ready. I am here to tell you it can be done!

Dr. Mehta is a hospitalist and director of quality & performance and patient experience at Vituity in Emeryville, Calif. She is vice chair of the SHM patient experience committee and executive board member of the SHM San Francisco Bay Area chapter.

It was 6 a.m. on a rainy, cold Pacific Northwest morning as I walked from my apartment to the hospital, dodging puddles and dreaming of the mediocre-yet-hot physician-lounge coffee. Another long day full of clinical and administrative tasks awaited me.

I was 6 months’ pregnant with our first child and working my sixth 12-hour shift in a row. We had recently lost our medical director, and the C-suite had offered me the role. The day ahead seemed like an enormous mountain to climb.

I felt tired and more than a little overwhelmed. But I whispered to myself: “Today is going to be a fantastic day. I will not fail my team. I will not fail my patients!”
 

Physician leadership starts with a decision

The timing of this call to leadership had not been ideal. There’s probably never a perfect time to step into a medical director role. And my situation was no exception.

In addition to the baby on the way, my husband was traveling a lot for work. Also, the job of a medical director seemed a little daunting – especially to a young physician leading a team for the first time.

But I knew that leadership was my calling. While I didn’t yet have decades of experience, I had been selected as the chief resident in internal medicine, completed a nephrology fellowship, and mentored several medical students and residents along my career path.

I also knew that I was passionate about supporting my patients and hospitalist team. I’d previously served as associate medical director in charge of quality, readmission reduction, and patient experience. Having achieved the highest patient satisfaction scores on the team for 2 consecutive years, I was specially tasked to improve our team’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

These experiences taught me that coaching with positive reinforcement was in my blood. This gave me the courage to face my tallest mountain yet.
 

No one climbs a mountain alone

I also stepped into my new physician leadership role with amazing support. Our outgoing medical director had recommended me, and my entire team was rooting for me. My spouse was 100% behind the idea.

Courtesy Dr. Swati Mehta

What’s more, I had received amazing feedback from patients throughout my 3 years at the hospital. I had papered an entire office wall with their thank-you notes. I even had a quilt that an 85-year-old patient’s wife made to thank me for my compassionate care.

As I weighed my decision, I realized that I had a higher calling to be a true advocate for my patients. I loved what I did. Each day, I resolved to bring my best and most authentic self for them – no matter how drained I felt.

My team and patients needed me now, not at some more convenient time down the road. A medical director job was the natural next step for me. And so, I resolved to climb the mountain.
 

Climbing through storms

Stepping into a medical director job forced me to grow into a completely new person. So maybe starting that role during pregnancy was a great metaphor!

Each day, there was immense pressure to perform, to deliver quality outcomes, and to simultaneously meet expectations of the C-suite as well as my hospitalist team. There was no room for failure, because too much was at stake.

Looking back today, I wouldn’t trade the experience for anything. The medical director role was one of the most gratifying experiences in my life, and I am truly thankful for it.

A leader’s role truly boils down to working tirelessly to collaborate with different care teams. It’s important to care not only about our patients but also about our fellow hospitalists. We can do this by truly leading by example – be it picking up extra shifts, covering holidays so team members can be with family, or coming in at 10 p.m. to round with your night team.

I was also able to bring a unique perspective to the hospital C-suite meetings as a woman, an immigrant, and a true “mama bear” – not only of my infant son but also of my team.

Courtesy Dr. Swati Mehta

My first year as a medical director required more commitment and heart than I could have imagined. But all this hard work paid off when our hospitalist group received the coveted Best Team Award for most improved quality outcomes, financial performance, and patient experience.
 

The summit is the beginning

My first medical director job fueled my passion for patient satisfaction even further. I now serve as the director of patient experience for the more than 4,200 clinicians at Vituity. Together we care for more than 6.5 million lives a year across the country.

In 2019, I coached 300 physicians and hospital leaders on communication, collaboration, and service recovery skills, leading to significant improvement in their HCAHPS scores. I was delighted to receive the Vituity Distinguished Service Award for my contributions. It’s such an honor to be instrumental in impacting patient care at a larger scale.

This year, I was invited to serve as vice chair of the Society for Hospital Medicine’s patient experience committee and to join the executive board of the SHM San Francisco chapter. Together, we have created a COVID-19 patient communication resource and reached out to our hospitalists to provide them with a space to share their stories during this pandemic. I am so excited to share my knowledge and passion with clinicians across the country given the wide reach of Vituity & SHM!

Many hospitalists shy away from leadership roles. The mountain is tough to scale, but the view from the top is worth it. The key is to start, even if you don’t feel ready. I am here to tell you it can be done!

Dr. Mehta is a hospitalist and director of quality & performance and patient experience at Vituity in Emeryville, Calif. She is vice chair of the SHM patient experience committee and executive board member of the SHM San Francisco Bay Area chapter.

It was 6 a.m. on a rainy, cold Pacific Northwest morning as I walked from my apartment to the hospital, dodging puddles and dreaming of the mediocre-yet-hot physician-lounge coffee. Another long day full of clinical and administrative tasks awaited me.

I was 6 months’ pregnant with our first child and working my sixth 12-hour shift in a row. We had recently lost our medical director, and the C-suite had offered me the role. The day ahead seemed like an enormous mountain to climb.

I felt tired and more than a little overwhelmed. But I whispered to myself: “Today is going to be a fantastic day. I will not fail my team. I will not fail my patients!”
 

Physician leadership starts with a decision

The timing of this call to leadership had not been ideal. There’s probably never a perfect time to step into a medical director role. And my situation was no exception.

In addition to the baby on the way, my husband was traveling a lot for work. Also, the job of a medical director seemed a little daunting – especially to a young physician leading a team for the first time.

But I knew that leadership was my calling. While I didn’t yet have decades of experience, I had been selected as the chief resident in internal medicine, completed a nephrology fellowship, and mentored several medical students and residents along my career path.

I also knew that I was passionate about supporting my patients and hospitalist team. I’d previously served as associate medical director in charge of quality, readmission reduction, and patient experience. Having achieved the highest patient satisfaction scores on the team for 2 consecutive years, I was specially tasked to improve our team’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores.

These experiences taught me that coaching with positive reinforcement was in my blood. This gave me the courage to face my tallest mountain yet.
 

No one climbs a mountain alone

I also stepped into my new physician leadership role with amazing support. Our outgoing medical director had recommended me, and my entire team was rooting for me. My spouse was 100% behind the idea.

Courtesy Dr. Swati Mehta

What’s more, I had received amazing feedback from patients throughout my 3 years at the hospital. I had papered an entire office wall with their thank-you notes. I even had a quilt that an 85-year-old patient’s wife made to thank me for my compassionate care.

As I weighed my decision, I realized that I had a higher calling to be a true advocate for my patients. I loved what I did. Each day, I resolved to bring my best and most authentic self for them – no matter how drained I felt.

My team and patients needed me now, not at some more convenient time down the road. A medical director job was the natural next step for me. And so, I resolved to climb the mountain.
 

Climbing through storms

Stepping into a medical director job forced me to grow into a completely new person. So maybe starting that role during pregnancy was a great metaphor!

Each day, there was immense pressure to perform, to deliver quality outcomes, and to simultaneously meet expectations of the C-suite as well as my hospitalist team. There was no room for failure, because too much was at stake.

Looking back today, I wouldn’t trade the experience for anything. The medical director role was one of the most gratifying experiences in my life, and I am truly thankful for it.

A leader’s role truly boils down to working tirelessly to collaborate with different care teams. It’s important to care not only about our patients but also about our fellow hospitalists. We can do this by truly leading by example – be it picking up extra shifts, covering holidays so team members can be with family, or coming in at 10 p.m. to round with your night team.

I was also able to bring a unique perspective to the hospital C-suite meetings as a woman, an immigrant, and a true “mama bear” – not only of my infant son but also of my team.

Courtesy Dr. Swati Mehta

My first year as a medical director required more commitment and heart than I could have imagined. But all this hard work paid off when our hospitalist group received the coveted Best Team Award for most improved quality outcomes, financial performance, and patient experience.
 

The summit is the beginning

My first medical director job fueled my passion for patient satisfaction even further. I now serve as the director of patient experience for the more than 4,200 clinicians at Vituity. Together we care for more than 6.5 million lives a year across the country.

In 2019, I coached 300 physicians and hospital leaders on communication, collaboration, and service recovery skills, leading to significant improvement in their HCAHPS scores. I was delighted to receive the Vituity Distinguished Service Award for my contributions. It’s such an honor to be instrumental in impacting patient care at a larger scale.

This year, I was invited to serve as vice chair of the Society for Hospital Medicine’s patient experience committee and to join the executive board of the SHM San Francisco chapter. Together, we have created a COVID-19 patient communication resource and reached out to our hospitalists to provide them with a space to share their stories during this pandemic. I am so excited to share my knowledge and passion with clinicians across the country given the wide reach of Vituity & SHM!

Many hospitalists shy away from leadership roles. The mountain is tough to scale, but the view from the top is worth it. The key is to start, even if you don’t feel ready. I am here to tell you it can be done!

Dr. Mehta is a hospitalist and director of quality & performance and patient experience at Vituity in Emeryville, Calif. She is vice chair of the SHM patient experience committee and executive board member of the SHM San Francisco Bay Area chapter.

Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.

While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.

Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.

Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.

While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.

Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.

Each year, the Society of Hospital Medicine celebrates the exemplary actions and successes of its members through the Awards of Excellence program. Nominations open every fall, providing the SHM community with the opportunity to nominate a peer, or themselves, to receive an esteemed award of excellence in an array of categories including Teaching, Outstanding Service in Hospital Medicine, Research, and so many others.

While the program and its Awards Committee review nominations with a predetermined set of criteria, excellence is not a ‘one-size-fits-all’ defined term.

Ms. Cowan is the marketing communications specialist at the Society of Hospital Medicine.

The American Board of Internal Medicine has named David Pizzimenti, DO, to its board of trustees. The appointment comes with a 3-year term.

Dr. Pizzimenti has been a practicing internist in Mississippi since 2005. He currently serves as associate medical officer of acute care at North Mississippi Medical Center, Tupelo, where he also directs the hospitalist program and the internal medicine residency program. Prior to joining NMMC, he managed the same role at Magnolia Regional Health Center (Corinth, Miss.).

Dr. Pizzimenti is an inducted member of the American College of Osteopathic Internist College of Fellows, as well as a certified wound care specialist.



Tommy Ibrahim, MD, FHM, recently was named the new president and CEO for Bassett Healthcare Network, replacing William Streck, who had served in the role from 1984 to 2014, and then on an interim basis since 2018.

Dr. Ibrahim comes to Bassett from Integris Health, the largest nonprofit health care system in Oklahoma, where he was executive vice president and chief physician executive. He started his career as a hospitalist before moving into administration, and is a fellow in hospital medicine as well as a fellow of the American College of Healthcare Executives.

Bassett Healthcare Network is based at Bassett Medical Center in Cooperstown, N.Y., and includes four hospitals and more than two dozen primary care centers in eight New York counties.
 

Russell Kerbel, MD, MBA, has been named medical director for sepsis prevention at the University of California, Los Angeles. Since his arrival at UCLA in 2014, Dr. Kerbel – a hospitalist by training – has worked to increase awareness and standardize sepsis treatment through his advocacy, interdepartmental collaboration, and informatics knowledge.

Joshua Lenchus, DO, RPh, SFHM, was installed as vice president of the Florida Medical Association during the all-virtual 2020 FMA annual meeting in August. Dr. Lenchus is a hospitalist and chief medical officer at the Broward Health Medical Center in Fort Lauderdale, Fla.

Christopher Carpenter, MD, has been elevated to chief of staff at Natividad, a 172-bed, county-owned hospital in Salinas, Calif. Dr. Carpenter has served Natividad for the past 4 years, holding the positions of chief hospitalist, chief of service for pediatrics, vice chief of staff, and most recently director of pediatric services.

Dr. Carpenter’s term as chief of staff is limited to 2 years, during which he said his goals include promoting diversity within the facility’s leadership.

Prior to arriving at Natividad, Dr. Carpenter was instructor of pediatrics at Harvard Medical School, Boston, as well as associate director of the Boston Children’s Hospital Pediatric Global Health Fellowship.


David Fagan, MD, recently was promoted to medical director at Mid-State Health Center (Plymouth, N.H.), where he has served for the past 10 years. The 30-year medical veteran began working in his new role in May 2020.

Previously, Dr. Fagan has served the facility as an internist and hospitalist, and he has been among the leaders at Mid-State in ensuring safety for patients and staff during the COVID-19 response.


The Carroll County Memorial Hospital (Carrolton, Mo.) recently announced its new hospitalist program, which officially began on June 1, 2020. CCMH officials said the focus of the hospitalists will be to maintain communication with primary care physicians once patients leave the hospital facility.

CCMH added three physicians to its staff to work in the hospitalist program: Reuben I. Thaker, MD; Samuel C. Evans, MD; and Charles C. Glendenning, DO.


NorthShore University HealthSystem (Evanston, Ill.) has agreed to purchase Northwest Community Healthcare, a single-hospital health system located in Arlington Heights, Ill. NCH will become a hospital hub for NorthShore in the northwest Chicago suburbs.

When the agreement is finalized, NorthShore’s stable of hospitals will rise to six in and around Chicago. The system also provides outpatient care, labwork, and pharmacy services.

The American Board of Internal Medicine has named David Pizzimenti, DO, to its board of trustees. The appointment comes with a 3-year term.

Dr. Pizzimenti has been a practicing internist in Mississippi since 2005. He currently serves as associate medical officer of acute care at North Mississippi Medical Center, Tupelo, where he also directs the hospitalist program and the internal medicine residency program. Prior to joining NMMC, he managed the same role at Magnolia Regional Health Center (Corinth, Miss.).

Dr. Pizzimenti is an inducted member of the American College of Osteopathic Internist College of Fellows, as well as a certified wound care specialist.



Tommy Ibrahim, MD, FHM, recently was named the new president and CEO for Bassett Healthcare Network, replacing William Streck, who had served in the role from 1984 to 2014, and then on an interim basis since 2018.

Dr. Ibrahim comes to Bassett from Integris Health, the largest nonprofit health care system in Oklahoma, where he was executive vice president and chief physician executive. He started his career as a hospitalist before moving into administration, and is a fellow in hospital medicine as well as a fellow of the American College of Healthcare Executives.

Bassett Healthcare Network is based at Bassett Medical Center in Cooperstown, N.Y., and includes four hospitals and more than two dozen primary care centers in eight New York counties.
 

Russell Kerbel, MD, MBA, has been named medical director for sepsis prevention at the University of California, Los Angeles. Since his arrival at UCLA in 2014, Dr. Kerbel – a hospitalist by training – has worked to increase awareness and standardize sepsis treatment through his advocacy, interdepartmental collaboration, and informatics knowledge.

Joshua Lenchus, DO, RPh, SFHM, was installed as vice president of the Florida Medical Association during the all-virtual 2020 FMA annual meeting in August. Dr. Lenchus is a hospitalist and chief medical officer at the Broward Health Medical Center in Fort Lauderdale, Fla.

Christopher Carpenter, MD, has been elevated to chief of staff at Natividad, a 172-bed, county-owned hospital in Salinas, Calif. Dr. Carpenter has served Natividad for the past 4 years, holding the positions of chief hospitalist, chief of service for pediatrics, vice chief of staff, and most recently director of pediatric services.

Dr. Carpenter’s term as chief of staff is limited to 2 years, during which he said his goals include promoting diversity within the facility’s leadership.

Prior to arriving at Natividad, Dr. Carpenter was instructor of pediatrics at Harvard Medical School, Boston, as well as associate director of the Boston Children’s Hospital Pediatric Global Health Fellowship.


David Fagan, MD, recently was promoted to medical director at Mid-State Health Center (Plymouth, N.H.), where he has served for the past 10 years. The 30-year medical veteran began working in his new role in May 2020.

Previously, Dr. Fagan has served the facility as an internist and hospitalist, and he has been among the leaders at Mid-State in ensuring safety for patients and staff during the COVID-19 response.


The Carroll County Memorial Hospital (Carrolton, Mo.) recently announced its new hospitalist program, which officially began on June 1, 2020. CCMH officials said the focus of the hospitalists will be to maintain communication with primary care physicians once patients leave the hospital facility.

CCMH added three physicians to its staff to work in the hospitalist program: Reuben I. Thaker, MD; Samuel C. Evans, MD; and Charles C. Glendenning, DO.


NorthShore University HealthSystem (Evanston, Ill.) has agreed to purchase Northwest Community Healthcare, a single-hospital health system located in Arlington Heights, Ill. NCH will become a hospital hub for NorthShore in the northwest Chicago suburbs.

When the agreement is finalized, NorthShore’s stable of hospitals will rise to six in and around Chicago. The system also provides outpatient care, labwork, and pharmacy services.

The American Board of Internal Medicine has named David Pizzimenti, DO, to its board of trustees. The appointment comes with a 3-year term.

Dr. Pizzimenti has been a practicing internist in Mississippi since 2005. He currently serves as associate medical officer of acute care at North Mississippi Medical Center, Tupelo, where he also directs the hospitalist program and the internal medicine residency program. Prior to joining NMMC, he managed the same role at Magnolia Regional Health Center (Corinth, Miss.).

Dr. Pizzimenti is an inducted member of the American College of Osteopathic Internist College of Fellows, as well as a certified wound care specialist.



Tommy Ibrahim, MD, FHM, recently was named the new president and CEO for Bassett Healthcare Network, replacing William Streck, who had served in the role from 1984 to 2014, and then on an interim basis since 2018.

Dr. Ibrahim comes to Bassett from Integris Health, the largest nonprofit health care system in Oklahoma, where he was executive vice president and chief physician executive. He started his career as a hospitalist before moving into administration, and is a fellow in hospital medicine as well as a fellow of the American College of Healthcare Executives.

Bassett Healthcare Network is based at Bassett Medical Center in Cooperstown, N.Y., and includes four hospitals and more than two dozen primary care centers in eight New York counties.
 

Russell Kerbel, MD, MBA, has been named medical director for sepsis prevention at the University of California, Los Angeles. Since his arrival at UCLA in 2014, Dr. Kerbel – a hospitalist by training – has worked to increase awareness and standardize sepsis treatment through his advocacy, interdepartmental collaboration, and informatics knowledge.

Joshua Lenchus, DO, RPh, SFHM, was installed as vice president of the Florida Medical Association during the all-virtual 2020 FMA annual meeting in August. Dr. Lenchus is a hospitalist and chief medical officer at the Broward Health Medical Center in Fort Lauderdale, Fla.

Christopher Carpenter, MD, has been elevated to chief of staff at Natividad, a 172-bed, county-owned hospital in Salinas, Calif. Dr. Carpenter has served Natividad for the past 4 years, holding the positions of chief hospitalist, chief of service for pediatrics, vice chief of staff, and most recently director of pediatric services.

Dr. Carpenter’s term as chief of staff is limited to 2 years, during which he said his goals include promoting diversity within the facility’s leadership.

Prior to arriving at Natividad, Dr. Carpenter was instructor of pediatrics at Harvard Medical School, Boston, as well as associate director of the Boston Children’s Hospital Pediatric Global Health Fellowship.


David Fagan, MD, recently was promoted to medical director at Mid-State Health Center (Plymouth, N.H.), where he has served for the past 10 years. The 30-year medical veteran began working in his new role in May 2020.

Previously, Dr. Fagan has served the facility as an internist and hospitalist, and he has been among the leaders at Mid-State in ensuring safety for patients and staff during the COVID-19 response.


The Carroll County Memorial Hospital (Carrolton, Mo.) recently announced its new hospitalist program, which officially began on June 1, 2020. CCMH officials said the focus of the hospitalists will be to maintain communication with primary care physicians once patients leave the hospital facility.

CCMH added three physicians to its staff to work in the hospitalist program: Reuben I. Thaker, MD; Samuel C. Evans, MD; and Charles C. Glendenning, DO.


NorthShore University HealthSystem (Evanston, Ill.) has agreed to purchase Northwest Community Healthcare, a single-hospital health system located in Arlington Heights, Ill. NCH will become a hospital hub for NorthShore in the northwest Chicago suburbs.

When the agreement is finalized, NorthShore’s stable of hospitals will rise to six in and around Chicago. The system also provides outpatient care, labwork, and pharmacy services.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.

HM20 Virtual session title

Call Me Maybe: Balancing Resident Autonomy with Sensible Supervision

Presenter

Daniel Steinberg, MD, SFHM, FACP

Session summary

In this session, Dr. Steinberg, professor of medicine and medical education, associate chair for education, and residency program director in the department of medicine at Icahn School of Medicine at Mount Sinai, New York, presented key factors, techniques, and approaches to supervising residents. He discussed the important balance of resident autonomy and supervision, especially since attendings need to focus on learner education along with patient care and safety.

Dr. Steinberg stated that resident supervision is driven by three factors: what residents need, what residents want, and what the supervisor can provide. Although data is mixed on whether supervision improves patient outcomes, supervision is essential for patient care and resident education. Dr. Steinberg showcased several relevant medical education studies relating to supervision and focused on a key question: Do you trust the resident?

The review of medical education literature discussed the meaning and development of trust, oral case presentations to determine trust, and the influence of supervisor experience. One study looked at the attendings’ remote access of EMR, which allows for remote supervision as a great way to determine trust of the resident. Another study showed that attendings want more communication than what residents provide and that the saying “Page me if you need me” does not encourage communication from residents as much as attendings would desire.
 

Key takeaways

• Resident supervision is driven by what residents need, what residents want, and what the supervisor can provide.
• Trust can be determined from direct supervision, oral presentations, and remote access of EMR, but it is also influenced by attending experience and style.
• To increase resident communication with the attending, do not say “Page me if you need me.” Instead, an attending should specifically state when a call to an attending is required.

Dr. Tantoco is an academic med-peds hospitalist practicing at Northwestern Memorial Hospital in Chicago and Ann & Robert H. Lurie Children’s Hospital of Chicago. She is an instructor of medicine (hospital medicine) and pediatrics at Northwestern University, also in Chicago.