Sunday, July 14, 2002

Great Leaders have great flaws . . . and you do too.

So do I. But, that’s not the point is it? All of us could be better somehow, yet we manage to serve and succeed to some degree most of the time. Yes, our flaws may bring us low or even bring us down, but they are part of the package.

Much of the advice historically offered to developing leaders was along the lines of, “Learn to go to your left.” In other words you should work to improve your weaknesses. Today, most psychologists and teachers and researchers of management principles instead point to the importance of playing to your strengths and working with others in collaboration to support your personal weaknesses. Such collaboration, if robust and focused upon the mission at hand is not brought down by personal differences when all participants have agreed to and are aligned around the same agenda.

In clinical practice that agenda or “Mission Statement” may be as simple as, “Practice high quality medicine for which we receive fair compensation while supporting the mission of our practice site—our community’s hospital.” An academic practice may incorporate its academic missions of research and teaching in its one sentence statement. Regardless, adhering to the mission is sure to require the collective efforts of the entire practice if for nothing else covering the schedule. Yet, even at this level swapping shifts after the schedule is published requires a degree of collaboration . . . and trust, that your colleague will do likewise for you when you need it.

How does one build such collaboration, particularly in a small single hospital group practice, and keep it on track as the individual personalities all pursue individual priorities?

The many small courtesies such as swapping shifts on short notice and working together to the same standard of practice build this bond over time, but what about the situation where someone who’s been part of the collaboration seemingly leaves the fold? Rarely manifested through a single startling deviation but more likely through a (too) protracted series of small infractions, how do you address the trouble? Unfortunately, some physician leaders, myself among them, may prefer to minimize or otherwise cover for the colleague whose behaviors create difficulties in the larger collaboration. Wanting to wish the bad behaviors away is all too human—and flawed.

Confronting our colleague’s deviations with them is the only solution. Challenge the behaviors, not the individual is easy advice, but hard in practice. Postponing the confrontation—waiting for the pressure to build—and tackling the conflict after upset has turned to exasperation and anger is a sure route to the feared commotion that rather than lasting a day may lead to substantial, prolonged or even complete disruption of your practice. Whatever the inciting event or events: whether you fear your colleague’s behavior originates through a substance abuse problem, personal or family upset or even the manifestation of a character flaw long suppressed, confronting the behavior is the essential first step.

Do not roll this confrontation into the fact-finding phase should the precipitating event be of sufficient magnitude that an investigative process is required. Complete the investigation and have all the facts in hand before confronting your colleague. If possible, gain your colleague’s agreement to the facts separately and prior to scheduling the confrontation.

Tackle the confrontation in a private circumstance. While your impulse may be to address the problem over food in a restaurant, you are probably better off meeting your colleague in a more structured and formal environment. An office is not necessary and may be counter-productive, but a conference room in the hospital that can be scheduled could be a good choice. Make sure you have sufficient time, don’t schedule yourself for a half-an-hour between other already scheduled meetings. If possible, schedule two hours even if you only plan for 20 minutes.

Begin by acknowledging how difficult it is for you to have “forced this meeting.” Recount as best as you can recall the specific event or events that troubled you so much that you scheduled the meeting. Focus on the behaviors that distressed you and explain your distress. Speak in the active voice and put yourself on the line. Don’t accuse or attempt to explain the behavior. State your shock and distress and why the behavior is not acceptable.

Two years ago I suggested that a practice leader could adopt the pyramid of medical staff development, even at the department level. I pointed to “the interlocking components of setting expectations, measuring and giving feedback as [are] the key components of the change process.” I went on to assert that, “Like you, I believe that most physicians want to ‘do the right thing.’ Unfortunately, most of us are increasingly uncertain as to what the ‘right thing’ is these days, which is why clearly setting expectations is so important [to beginning measurement.]”

The exact same statement of expectations is the key to either remedying the commotion in your practice or identifying the magnitude of the problem so that you can confidently take definitive action. You’re giving feedback now, perhaps without having previously, explicitly stated expectations, so reaching the occasion where you can take definitive action will take additional time, which must be expended. For when addressing behavior, acting on the past events—unless heinous and of imminent risk to patients or staff—is not sustainable. For a colleague and collaborator, the chance to right themselves must be offered. Whatever the “bad behavior” you must describe, demand that it stop, describe the behavior that is desired and observe for the correct behavior. If found, praise it; if behavior reverts to that for which your colleague has already been rebuked, then you must discipline your colleague. Or otherwise intervene, perhaps in accordance with JCAHO Standard MS.2.6 if appropriate.[1]

Delayed response to disrupting behavior within a close-knit group of collaborators is a far too common flaw in leaders. It risks the entire collaboration. Confrontation though difficult to initiate is the only route to resolution.

[1]The medical staff implements a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function.