Author + information
- A. Allen Seals, MD, FACC, Immediate-Past Chair, ACC’s Board of Governors∗ ( and )
- Mark Hertling, Lieutenant General, U.S. Army (Ret)
- ↵∗Address for correspondence:
Dr. A. Allen Seals, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
Effective medical leadership is vital in delivering high-quality health care and building interprofessional health care teams. Currently, there is a critical need to involve physicians in significant roles in our increasingly complex health care environment. Cardiovascular specialists are uniquely positioned to fill these leadership roles—in private clinics, in local hospitals, and in medical centers, as well as in nonpatient care positions in insurance, regulatory, and governmental institutions.
The Physician Leadership Imperative
The reality of our health care system is that quality cardiovascular care demands the utilization of complex medical care, often involving novel pharmacological treatments, complex interventional procedures, and prolonged outpatient treatment plans. The demands on the health care system become increasingly more complex when patients must interact with multiple medical specialists and navigate through a maze of diagnostic facilities, outpatient clinics, and inpatient hospitalizations. Most of this medical care takes place under the external influence of insurance-based authorization review, regulatory oversight of the utilization of resources, and government quality-based payment programs as most recently mandated under the Medicare Access and CHIP Reauthorization Act.
The Harvard Business Review has addressed this complexity of our health care systems, and the need for innovative and consistently evolving physician leadership development. In a paper titled “Turning Doctors into Leaders,” Thomas H. Lee, MD, writes that “to effectively attack this chaos, we need a new kind of leadership at every level of the health care system” (1). For cardiologists, this will require not only a commitment to constantly improving medical skills, but also a foundation of strong personal and professional values and a broad understanding of the complex inter-related medical systems of care, while simultaneously complementing those competencies with an increased range of nontechnical leadership skills that will help them lead across professional boundaries.
While quality medical care clearly requires good medical leadership, the training of good medical leaders has not previously been a traditional role of graduate medical education programs or the post-graduate practice environment. In the past, if addressed at all, the typical training curricula would suggest coursework in “communication skills,” “negotiation techniques,” “business acumen,” or “time management.” After leaving training, the young physician is too often limited to continue medical education focused on clinical sciences and training, while formal leadership training is reserved for health care administrators. Practicing cardiologists in the conventional clinic and hospital settings often find that leadership skills are unfulfilling because they are all too often viewed as process oriented, or only “nice to have” competencies.
However, in 2015, with the broadly supported COCATS 4 (Core Cardiovascular Training Statement 4) and the parallel development of the Accreditation Council for Graduate Medical Education statement on the Next Accreditation System, training of leadership skills was formally accepted and implemented. Both COCATS 4 and Next Accreditation System embrace the philosophy that modern-day cardiologists “participate in a team-based system, use information technology, practice cost-effective medicine, and importantly, help them function as a health care leader” (2).
Translating the Military Leadership Model to the Health Care Landscape
A few years ago, a hospital system in Florida began using a military training model to contribute to improving the leader attributes and competencies possessed by their physicians. Adapting a definition of leadership used by soldiers, this program further refined an encompassing definition of leadership that could guide physicians in improving health care teams and patient engagement (3). That definition, borrowed from a military training manual, but adapted to the demands of health care, reads that “leadership is the art of understanding motivations, influencing people and teams, and communicating purpose and direction to accomplish stated goals while improving the organization” (4). In the U.S. military—like in medicine—life or death scenarios are often presented. Similarly, in the military as it is in medicine, it is a requirement of leaders to bring a group of differentially skilled individuals together as a high-performing team to succeed in a mission. Although at first the military is seemingly an unlikely source for leadership skills in health care, the U.S. Army employs a number of applicable and simple techniques and models to build leadership skills. One of the most translatable of these is the “Be, Know, Do” leadership model. The “Be” is all about character. It reflects who a leader is and how he or she is perceived. The “Know” is a leader’s knowledge and understanding of skills required to do his or her job and perform. Finally, “Do” is where action takes hold—how does the leader generate trust? How does the leader develop others to contribute to the organization to accomplish goals and meet the mission? Although the “Be” and “Know” tenets of this leadership model are incredibly important, it is in the action-oriented “Do” portion where leaders can struggle. Failure in leadership occurs when an idea or decision makes it to the point of action, and there is no one there to drive it to finality. The core of leadership is that effective leaders take action and get things done.
What Makes an Effective Leader?
Two concepts help define an effective leader: individual attributes and emotional intelligence. The development of strong personal and professional values remains the most fundamental prerequisite for the individual character that defines an effective leader. Most leaders come to the table with the best of intentions, but unfortunately these individuals typically lead with only 1 lens—their own. It is not until leaders take a look around—gain situational understanding, sense the culture and the dynamics of the surroundings, and gather feedback—that their self-perception is either validated or disproved. Self-awareness, a key component embedded in individual attributes and emotional intelligence, is a key factor of leading effectively. The higher the level of leadership, the more crucial personal character becomes, and in fact, individual attributes and emotional intelligence often trump scholarly intelligence in contributing to leadership effectiveness. Thus, in the health care management setting requiring effective leadership, there is an increasing need to focus on competencies related to how we work together, communicate with each other, and manage positive change (3).
Effective leaders cannot remain effective if they lose their sense of humility and self. Whether one is serving as an Army commander or as a physician medical director in a hospital, self-reflection is an important part of the leadership journey. Harvard Business Review author Anthony K. Tjan states this same self-awareness “…allows the best business-builders to walk the tightrope of leadership: projecting conviction while simultaneously remaining humble enough to be open to new ideas and opposing opinions” (5).
Cardiovascular professionals operate within constantly shifting local environments and a rapidly changing national health care landscape. It is no surprise that leaders in health care often only focus on the task at hand. In contrast, an effective physician leader considers how to lead from a 360° perspective, and proven and accomplished leaders demonstrate the ability to incorporate new ideas and concepts each day and over time. Stakeholders matter and their perception of how physician leaders execute their role matters even more. Leaders must take the time to seek feedback from these involved stakeholders, actively engage peer colleagues, as well as seek advice from other team members. And, while doing so, the leader must actively listen and be prepared for honest critiques. As the Greek philosopher Epictetus wrote, “We have two ears and one mouth so that we can listen twice as much as we speak” (6).
Beyond the fundamentals of personal character (intellectual attributes and emotional intelligence), organizational-based leadership skills or competencies are also critical to effective leadership. Most organizations maintain a set of core leadership skills that are critical to conducting business each day. These leadership skills, or competencies, are reflective of one’s culture and leadership expectation. The military uses a “leadership requirements model” that, based on years of research, centers on who the leader is and what the leader knows—or the leader’s attributes—and what the leaders does—or his or her competencies (3).
The American College of Cardiology (ACC), as part of its new governance transformation, is leading the way in physician professionalism and leader development by defining key leadership competencies and incorporating them into the organizational structure of the College. Beginning with the Board of Trustees, these principles of leadership competency are now being implemented through the entire ACC leadership structure—including selection of chairs and members in all committees, sections, and councils. The 5 competencies representing leadership skills that the College considers fundamental for an ACC leader include: exhibits influential leadership, demonstrates business-focused proficiency, demonstrates strategic leadership, anticipates and leads change, and maintains organizational awareness and stewardship. These competencies are presented with the fundamental premise that the ACC leader will respect others, remain selfless, and always remain focused on delivering results (7). In addition, the ACC has added leadership and administrative competencies to its ACC’s Lifelong Learning Competencies Educational Portfolio alongside the 18 areas of clinical expertise. This is yet another acknowledgment from the College that cardiovascular specialists must be effective leaders in efforts to ensure high-quality care and promote individual and population health (8).
How to Build an Empowered, Highly-Effective Health Care Team
Effective leaders must first understand themselves and understand those around them. Then, an effective leader must master the art of being both a strong team builder and a strong team player. The military uses 7 characteristics to define effective teams: trust, standards, accountability, confidence, teamwork, challenge, and rewards. In a similar manner, a physician leader must understand how these characteristics contribute to high-performing teams, and then embrace the responsibilities inherent in each of these areas (3).
Effective versus ineffective leadership can make or break an institution or practice. Unfortunately, when there is a failure to meet a mission or health care system goal, it can often be tied to a leader’s failure to adhere to these characteristics of team building. “Toxic leaders”—those individuals who are defined as being more concerned with self-aggrandizement, personal gain, or professional recognition rather than care for the patient or contributions to health care—consistently ignore these tenets of team building, and consequently they often cause harm to their organization or to the profession. Stanford University professor Robert Sutton, PhD, has studied “toxic leaders” and writes that the negative effect that destructive leaders have on their organizations “is seen in the costs of increased turnover, absenteeism, decreased commitment to work, and the distraction and impaired individual performance documented in studies of psychological abuse, bullying and mobbing” (9). Toxic leaders can significantly damage an organization’s culture and function, and as Sutton implies, should be dealt with appropriately.
One of the most important ways physician leaders can connect with and build a strong team is by understanding the motivations of team members. Great leaders will find out what triggers others and tailor their leadership techniques and communication style to best reach each team member, or their patients. Great leaders listen and then determine the method of influence they will use before acting accordingly. This simple approach can be applied to large or small groups, or on an individual level. A good leader understands each member of the team because that leader has determined the team member’s motivation. When team members are understood and heard, they are empowered and invested, and they contribute much more to the organization’s goal.
When physicians grow as effective leaders, they grow both personally and professionally, and they learn skills to propel them as agents of change for better health care. It is imperative that physicians and cardiovascular team (CVT) members take expanded roles in health care institutions—both at the strategic and direction-setting level, and the day-to-day tactical operations. To land that coveted “seat at the table,” physicians must learn “table manners,” such as how to effectively lead and build productive, motivated teams (3).
The ACC’S Role in Developing the Next Generation of Leaders
On a national perspective, with the Triple Aim as a marker for success of the future of health care, the ACC is convinced that physician and CVT member leadership is critical to meeting the goals of improving health through better health, better outcomes, and lower costs. Empowering and arming both physicians and CVT members with leadership skills can help remove the divide that exists between health care providers and health care administrators. In an environment where the percent of U.S. gross domestic product spent on health care far outweighs defense spending, it is critical that America’s health care providers have the skills and tools to lead in important policy decisions.
The ACC has devoted considerable efforts and resources to addressing the critical need for College members to develop as leaders. The recently concluded 2017 ACC Leadership Forum adopted the theme: “Growing Leaders and Empowering Professionals to Improve Health Care.” A broad spectrum of ACC members heard from ACC leadership, including ACC President Mary Norine Walsh, MD, FACC, who discussed her personal leadership journey and what it means to lead “without title.” From her perspective, she highlighted 6 personal attributes—intellectuality, sociability, emotional stability, personality, physicality, and morality. Dr. Walsh described these attributes as characteristics that define individuals with the capacity to influence and act as true leaders.
The College is steadfastly committed to leadership development across the spectrum of ACC membership. In addition to the Leadership Forum, there are formal leadership programs within the College, including ACC’s Emerging Faculty Program, International Leadership Training Program, Board of Governors Mentoring Program, and ACC’s Leadership Academy. All of these ACC leadership training initiatives present College members with excellent opportunities to learn and grow as leaders within the structure of the College. As the ACC continues its charge to transform cardiovascular care and improve heart health, a strong foundation of leaders is critical to help the College accomplish its mission and to provide value to its members as they grow and become more effective, empowered leaders.
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- ↵Headquarters, Department of the Army. Army Leadership: Competent, Confident, Agile. Field Manual (FM) 6-22. October 2006.
- ↵Tjan AK. How leaders become self-aware. Available at: https://hbr.org/2012/07/how-leaders-become-self-aware. Accessed February 27, 2017.
- ↵Packard D. 5 important qualities for a medical leader (and one to avoid). Beckers Hospital Review 2015. Available at: http://www.beckershospitalreview.com/hospital-management-administration/5-important-qualities-for-a-medical-leader-and-one-to-avoid.html. Accessed February 27, 2017.
- ↵American College of Cardiology. Leadership competencies: serving as a leader at the ACC. Available at: http://www.acc.org/∼/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/About%20ACC/Leadership/BOT%20Nominations/2016-2017-Leadership-Competencies.pdf?la=en. Accessed February 27, 2017.
- ↵American College of Cardiology. Table 24: leadership and administrative competencies. Available at: http://www.acc.org/education-and-meetings/products-and-resources/competencies/table-24-leadership-and-administrative-competencies. Accessed February 27, 2017.
- Sutton R.I.