Category Archives: Leadership

Pathways to Building and Practicing Resilience

Disappointment, disruption, unfairness, failure, rejection and disease are part of being human.  We build a house of cards in our minds as to what ought to be and are devastated when it falls.  This pattern is one of the first to appear in our cognitive development; it’s also the most important, and certainly the most beautiful.  Given its importance, and the inevitable negative side of this human wonder, we need a recovery mechanism.  It’s called resilience.

Resilience is part of the biological world and it’s truly remarkable.  Cognitive resilience is uniquely human and likely in some respects genetic.  Nurturing inherent resiliency is an important part of being a parent, a grandparent, a teacher and a coach (I’ll add leader as well).  There are different pathways to resiliency, and the effective and timely deployment of a combination of these pathways is the secret.

The pathways are complex and interdependent; they’re physical, cognitive and emotional.  Some are fast, some slow, some require higher levels of cognitive function, and thus can’t be deployed until adolescence and young adulthood.  These pathways work in sequence and ni parallel; they work together like a complex circuit.  Personal experiences, learned behavior and chemical imbalances can interfere with these pathways.  These pathways need to be nurtured and practiced, and developed over time.  There are experts, but most of us always have a pathway or two that could use some strengthening.

The pathways are: self-awareness, tolerance, reframing, hope, self-determination, and action; I call them the Yep, OK, See, Can, Will, Do pathways.  As a pediatric oncologist I’ve seen a lot of disappointment and unfairness, and a lot of resilience.  I’ve seen these pathways in action.  The Yep, is acknowledging that this is bad, and that you’re sad or mad about it.  Feeling negative emotions is natural and human, it’s the depth and breadth we need to minimize to have resilience.  The first lesson we can model and coach is as follows, “It’s ok to feel bad, take a deep breath and try not to stay in that dark place too long.”

OK is sometimes accepting (but that’s hard), but mostly tolerating, or living with it so to speak.  We’ve all seen children do this step very quickly and we’ve all seen them take too long.  Why the difference?  Attachment.  The second lesson, “it is what it is, it happened, it’s in the past, it doesn’t need to take me over, or define who I am.”  You can probably see the developmental progression in that lesson.

See is my favorite; it is so uniquely human and has resulted in so many wonderful things.  It’s intuitive, but must be enabled.  It can be quick, or take a while.  It can be simple or it can be complex.  It can be constructive  or destructive.  Our role as parent, teacher, coach or leader is to enable and empower this pathway, by offering suggestions, modeling the way, or sometimes just telling them what to do.

Can is about hope and optimism.  Some call it a sense of self-efficacy or confidence.  Will is about self-determination and perseverance.  Do is perhaps intuitive, but the faster you can get to it, the better.  In fact, one ought not to seek perfection in the other pathways, or get lost in them at the expense of putting off action.

We ourselves need to have resilience when helping others use these pathways: Yep, controlling emotions is hard, Ok this takes time, I See another way to help, I believe this person Can do this, we Will do this together, let’s Do it.

Relationship-centered interactions

This unique and challenging, relatively sudden disruption to everyday life is an opportunity for us all to realize new ways of seeing life, be more aware of the balance in things, connect with our humanity, and grow as a person.  This includes how we communicate and interact with others.

Relationship-centered care is a frame for looking at how we as professionals approach working with others.  It starts with increasing one’s awareness of where they are as a person physically, mentally, emotionally and spiritually*, and letting that awareness inform hot buttons, biases, personality traits and other factors, which might impact the interaction.  It also allows for one to use self-compassion and be ok with where we are at that moment.  Self-compassion allows for an honest assessment of one’s current state, and allows wiggle room for imperfections.  Compassion for self is a presupposition for having compassion for others.  [*Spirituality simply refers to the way you relate to the world and your purpose in it.]

The next step in relationship-centered care is for one to be open to and as aware as they can to where the other person is currently.  Compassion for them as a person, for the challenges and struggles they bring with them, for their feelings as well as their thoughts.  Compassion is enabled by empathy,  and motivated by concern.  It’s fueled by virtue.  It may not be essential to a relationship or interaction, but it sure helps.

The third step is to see the relationship in the context of your team (or family), the neighborhood (or organization), and the community (or society).  Interactions are relational first, and situational second, and essentially never one or the other.  Certainly in most professional and educational interactions, they are contextual.

I’ve known about relationship-centered care for well over 10 years, and some elements come natural to me, or at least I’m naturally aware of them.  Yet I’m no expert practitioner, and that’s ok.  Each of us has certain genetic and experiential realities that make us imperfectly human.  There are invariably situational smoke screens that can cloud our vision of things.

Be kind to yourself, take a deep breath, be aware, and be positive in your interactions.  We’re all in this together.


A short course on human relations slightly expanded

An old poster some still have on their office wall called “A Short Course in Human Relations”  goes like this:

The SIX most important words:  “I admit I made a mistake”

The FIVE most important words:  “You did a good job”

The FOUR most important words:  “What is your opinion”

The THREE most important words:  “If you please”

The TWO most important words:  “Thank you”

The ONE most important word:  “We”

The LEAST most important word:  “I”

In my searches to find the origin, I came across a blog that told a story from the 1980s.  The author first saw the poster on her boss’ office wall.  The boss noticed she was studying it and said, “You know that’s not the whole course.  There is also the SEVEN most important words, ‘I don’t know, but I’ll find out.’  Now you know the complete course.”

What keeps people from saying these phrases and practicing their intent?   Perhaps they aren’t telling themselves the EIGHT most important words: “I have the courage to say these words.”

Now you know the complete revised course.  Here it is again:

The EIGHT most important words:  “I have the courage to say these words.”

The SEVEN most important words:  “I don’t know, but I’ll find out.”

The SIX most important words:  “I admit I made a mistake”

The FIVE most important words:  “You did a good job”

The FOUR most important words:  “What is your opinion”

The THREE most important words:  “If you please”

The TWO most important words:  “Thank you”

The ONE most important word:  “We”

The LEAST most important word:  “I”


Is Servant as Physician and Leader a Dead Concept?

Servant leadership: I’m concerned it’s dead.  It’s been suffering a deep malignancy for years, and it seems to be reaching the terminal phase.  The profession of medicine is dying along with it, because of the indivisible link between the two.  What happened?  Greed? Arrogance? Apathy? A decline in responsibility and ownership?

One possibility is that it was never alive to begin with, but merely an illusion.  I can’t name one doctor or leader I’ve met or been mentored by over the past 25 years I would like to be like.  There are those who have attributes I admire, and those who have attributes that I share, but none who I aspire to be.  Thus, I can only conclude that servant as physician and leader has always been and remains a rare anomaly.

Another possibility is that there is no energy or time to acquire the knowledge and skills or for the reflective listening needed to expand the awareness required to be a servant as leader and physician.  The lack of time has many contributing factors: the increasing complexity of practicing medicine, the immense breadth and depth of knowledge required, and the increasing amount of time required for EHR documentation, insurance-related administrative tasks, and various regulatory and licensing requirements.  A more positive reason for the lack of time is the shift to valuing wellness and balance if not synergy in one’s life, as well as the importance of being present with one’s family if you’ve decided to raise children.  Thus, some things had to go and among them were taking the time to learn the skills and behaviors to be a servant physician leader, and executing them on a regular basis.

A common root cause of both possibilities may be the lack of value individuals and society as a whole give to the concept of servant leadership or servant as physician.  Today there are conflicting priorities. One is forced to choose, often choosing with a natural self-centered bias.

Physicians often complain about RVUs, work hours and compensation; many want to make more money then complain about the focus on RVUs, which is how physicians get reimbursed.  Almost universally money eventually wins in this generative tension. What happens is that the physicians drive (perhaps unknowingly in some cases) an increasingly more efficient system designed to optimize revenue.  The resulting culture is: if a physician isn’t going to get paid for doing it, they won’t do it as much, or as well, or even at all.  Servant leadership often takes time and energy that has no RVUs attached to it.

I don’t have a cure, and it may already be dead.  I fear this lonely dream of servant as physician and leader will forever be securely stuck in the corners of my imagination.

The art of dialogue: an indispensable leadership skill

I became a physician “leader” frankly because staff asked me to change things or they would quit.   It started 17 years ago.  I was an informal “leader”, becoming increasingly formal over the next 5 years.  It was a rough road for many reasons, but my lack of skills, knowledge, awareness, maturity, preparedness, good mentoring, and sleep were at the top of the list.

Because I was so bad, I was given the gift of a professional coach, which was helpful with guiding my self-learning and reflecting. Thankfully, I was able to improve on some of my deficiencies; the one that I had to work on the most, both because of my ineptitude and the importance of it, was having discussions and dialogues with people.

I’m still learning and practicing dialogue. I wish it were easier, but its not. The biggest problem is that it takes time, which we don’t have a lot of. The second biggest problem is that we’re human, and have learned some unfortunate human habits. The biggest of these habits is a tendency to be defensive, to take things personally and to hold onto ideas and memories with too much dogma, blinding ideology, and just plain old-fashioned emotion. This internal milieu interferes with listening, learning, and most importantly thinking. We’ve all seen how egos and lack of humility (hubris) can derail good conversations, but that’s only part of the story. The other big problem we humans have is judging (criticus).   We judge, judge, judge.  Dialogue can be derailed by hubris and criticus. Being aware of these barriers is the first step, doing our best to abate them, without beating each other up about them, is the second.

Suppressing our hubris and criticus is important when having a dialogue, but without respect, appreciation, a desire to learn, and time, it still won’t happen. Stepping outside ourselves, our attachments and our preoccupations isn’t easy, but necessary.  Try asking yourself: do I really know everything that needs to be known? Is my view truly the only possible viewpoint that has merit? Have I thought of all the possibilities? Am I showing how much I care about the people in the room? What else might we face in the future that makes how we accomplish this conversation as important as what the conversation is about?

William Isaacs in his famous 1999 book Dialogue and the Art of Thinking Together describes 4 steps we can take when participating in dialogue: Listening, Respecting, Suspending and Voicing. Out of these 4, suspending is often the hardest (aside from leaving voicing until the end). Edgar Schein has talked about “accessing your ignorance” as a means to start the suspending process. To access one’s ignorance, one must pause, embrace humility and suspend judgment. This practice naturally leads to the advice that one ought to ask questions first, then voice their opinion second; seek to understand before being understood.  Questions are most effective when coming from a place of ignorance.

Dialogue is about reducing our collective ignorance.  It doesn’t make it completely go away, but we’re better prepared to face our challenges nonetheless, and face them together.


Over 10 years ago (and probably long before that) a paradigm of leadership different from the top-down approach started to surface: as highly educated and skilled people increasingly constitute the workforce , leaders must learn to lead leaders, not just followers.  As much as I’ve been a slow learner, it appears I’m not alone.  It wasn’t until this month’s Harvard Business Review that I discovered one root cause: most senior leaders, including board members, actually don’t appear to encourage, incentivize or even model the right kind of leadership needed today, and they don’t hire it.

Described in What Great CEOs Do Differently by the CEO Genome Project (HBR May/June 2017) are 4 behaviors of the most successful CEOs: 1) deciding with speed and conviction, 2) engaging for impact, 3) adapting proactively, and 4) delivering reliably.   In other words: set a course and believe in it, inspire and engage others, continuously learn, improve and renew, and deliver results consistently.

The article doesn’t really describe the genome, but rather gene expression.  They do mention in passing a few “genes” such as, “…while boards often gravitate to charismatic extroverts, introverts are more likely to exceed expectations…”

Mistakes boards make are because they focus on the downstream impact of gene expression.  Nearly all successful CEOs in this study had made rather significant mistakes in the past. Yet, boards and others who choose leaders shy away from anyone who’s made a large mistake.   High confidence improves the likelihood of a person being hired, but makes no difference in whether they’re successful or not (an example of focusing on the wrong gene expression).

There are a few more genes that others have pointed out that are supported by the CEO Genome project: 1) focusing on something bigger than themselves, and sacrificing themselves to that vision, 2) humility, and 3) …you guessed it… the ability to lead leaders, although this may not be the gene, just the expression.

The ability to inspire people who are leaders, especially those with a suboptimal leadership gene expression profile, eludes many of us.  Is it emotional intelligence?  No, a lot of good leaders have that.  I think it’s more fundamental than that.   I think its mindfulness or openness.  Mindfulness allows one to achieve a certain level of awareness, acceptance, humble inquiry, honest reflection, and caring with a sense of service.  It used to be called taking the higher road, calling it mindfulness begins to describe how to get there.

Total Leadership Revisited

Almost 10 years ago I heard an interview on NPR with Stewart Friedman regarding what was then a new book called Total Leadership. At the time I was nearing the end of a long recovery from burnout.  Total Leadership was one of the better books for helping me achieve better balance in my life, and for helping me envision a healthier professional life as a physician leader.

There are two major premises in his book: 1) by integrating your professional, personal, family and community realms, finding common ground and synergy, you can be a total “leader” and achieve better work-life balance, and 2) by being your self, your whole self, and respecting the whole of others, and embracing your creativity, you will find joy and fulfillment in what you do.

Perhaps the best active advice this book provided for me were those that involved reflection.   For example, acting with integrity (being whole) sounds easy, but when you reflect on key crucial moments you may discover that the values you hold dear when calm and collected, can sometimes take a back seat when the heat is on or when things don’t go well.  If you truly value respecting the diverse views of others then you’ll listen even when emotions are high. You don’t have to agree but you’re able to acknowledge and kindly consider their perspective, which by the way takes longer than a few seconds.   Another example is honesty and trustworthiness. Most of us value these, yet, we are often dogmatic about things, which when truly dissected, the facts of which aren’t quite as black and white. In other words we aren’t as dedicated to the truth as we are our attachments to our own biases, our own perspectives.

This last point, reflecting to get closer to the truth of things, is actually a key daily activity for beating burnout. Burnout spirals because our reality is adversely shifted by negative bias.  Be Real, Be Whole, Be Innovative and Be Reflective and you can reduce/prevent burnout.

Being innovative is more about experimenting with new ideas and new ways of doing things than it is about dreaming up the next big idea and thinking it will fix everything (remember be dedicated to the truth). True innovators are doers. Its action on an idea and learning from that action, which takes honest reflection that makes innovation truly energizing (and successful).  And energy is an antidote for burnout (and we all like succeeding).

One of the exercises described in this book is to write a vision of you as a Total Leader in 10 years.  It’s been almost 10 years and as I read what I wrote back then, I realize that I achieved the vision (mostly).  Thank you Stewart Friedman.

Versatility and Balance

It helps to be focused on a few priority goals and values. It’s nice to be able to describe your mission, vision and strategy in a quick elevator speech.   For a leader to have a few outstanding character traits and to be clear for what they stand are good as well. Yet, to be successful these must be balanced with the study and grasp of diverse and complex hard and soft data and the possession of environmental, organizational, and emotional intelligence.

Balance is key.   Flexibility and versatility are essential in today’s leadership environment.   The capacity for renewal and reinvention are increasingly important as well. I’ve become convinced that one reason humility and will are level 5 leadership traits is because they are necessary for achieving balance and versatility. And they are needed if one is going to leverage renewal and reinvention to stay relevant.

Kaplan and Kaiser articulated this concept of versatile leadership in a 2003 MIT Sloan Management Review article. They framed it as forceful leadership balanced with enabling leadership, and strategic leadership balanced with operational leadership. Awareness of these types and their vices and virtues can help a leader in today’s world of rapid change, generational differences, and unprecedented ambiguity.



Confidence is important, yet better if it comes from knowing which style to lean on, rather than always leaning on the style the leader knows best. Courage is required to take the risks of switching back and forth. And, of course, leaders must work on developing their competence in all 4 styles. Humility assists the leader in recognizing the need to shift to a different style, and the need to work on developing skills in those less used styles. Will assists the leader in overcoming the inevitable bumps that come from shifting.

For executive leaders, it is often helpful to verbalize to direct reports and others from which leadership perspective you are operating in a given situation and why. Versatility is essential, yet it can have its downsides. One of those pifalls is creating confusion regarding the roles and expectations of others on the team. Are we being strategic or operational? Forceful or enabling? Am I to be using the same style?

Knowing where to start and where to shift can be challenging. Wisdom derived from experience and thoughtful reflection aids this. Wisdom complements humility and will, and may in fact be the difference between the nimble versatile leader and the awkward novice.

So, be focused and use sound bites, stand up for your values and principles, be visionary and relational, yet not too much. Be careful not to slight the detail work of change management, performance improvement, and plan execution, yet not at the expense of ignoring the changing environmental forces and keeping an eye on the big picture. Don’t forget the importance of opening up dialogue and listening to others, and when needed be a forceful leader, communicating with clarity, and reframing and renewing in inspiring ways.



Narcissism: what keeps a high-achiever from being a great leader

With the awareness of saying something stupid comes learning and even at times insight. This awareness doesn’t erase one’s stupidity, but it may make one smarter for the future. I was recently talking with a friend about physician leaders and out leaked an incorrect generalizing comment. I suggested that physicians who tend to be self-centric in their view if not narcissistic aren’t good leaders. What I meant to say was that a lack of broad perspective is a barrier to being an effective leader, however, it may not be a barrier to positive contributions to organizational learning and problem-solving, not to mention being a good physician.  Dogmatic views and attachment to narrow perspectives can interfere with good leadership in complex, diverse and uncertain environments. However, in certain situations those qualities can be helpful. Not being a good listener is a problem if your leading a diverse group through complex issues, but good listeners (aka good leaders) like people who will speak up, and that’s were physicians, even those who are somewhat self-serving can contribute facts, ideas and insights.

As I tried to recover from my stupidity, a thought popped into my head. Could narcissistic physician leaders start to lose their effectiveness the more broadly their leadership asks them to think and function? What if they contribute quite well until they get to the executive leadership level? In 2012 Justin Menkes wrote a short article for the Harvard Business Review entitled: “Narcissism: the difference between high achievers and leaders.” He suggested that high achievers who are also narcissists can do very well to a point, however, at the executive level they can sink your company. The narcissism just gets in the way.

In 2000 and 2004 in the Harvard Business Review, Michael MacCoby published “Narcissistic leaders: the incredible pros, the inevitable cons” where he suggested that narcissistic leaders do have the advantage in certain situations, specifically where there is chaos or opportunity for innovation. Implied but not specifically stated in his article is that you have to be really good at what you’re doing (e.g Bill Gates, Jack Welch, etc.). Healthcare may be going through a lot of change, and some would claim chaos, but at the heart of providing health care is the patient, a person who doesn’t need chaos or change, they need high-reliability. Narcissism won’t get you that at the micro- or macro-system levels. Even beyond health care delivery, narcissism is potentially dangerous in healthcare. Just consider the case of Theranos and Elizabeth Holmes. Narcissism, even if you think you’re doing a good and just thing, gets in the way.


Communicating: some wise advice from Lao Tzu

For a leader one of the toughest challenges is communicating. Getting right the what and the how, the who and the when and even the where isn’t easy.  In certain situations, there is no perfect way.  Sometimes it’s not just what is said or how it’s said, but who is saying it that matters the most.   Effective communication starts with the speaker, the leader: their credibility and the level of trust the team or organization has in the leader.

Over the years I’ve worked hard at improving the effectiveness of my communication. With patients and families I’m effective most of the time, but there is always room to improve – the approach to communicating needs to be tailored to the individual, as well as the situation and circumstances – and that’s hard to get right every time.   Even within one episode of communication, the approach needs to be fluid.  This takes emotional intelligence and practice.

Lao Tau has some advice for communicators.  Lao Tau said, “He who knows does not speak.” He also said, “Practice doing ‘not doing’.” These two tenets of Daoism need to be front of mind when a leader is communicating.  He is telling us to listen – do more listening than speaking.

One can gain many lessons about communicating from Daoism. Daoism encourages one to consider that the whole is real and the divisive is perceptual.  A single idea or opinion cannot be good or bad, because that would place judgment, which is a comparative and perceptual approach not a synergistic or uniting one. To throw out an idea would threaten the balance of the whole.  Lao Tzu said, “Long and short complement each other.” Meaning you can’t have long unless you have short.  In communicating, one would do well to remember that nothing is really new, or better, or old or bad, it simply is, and whatever it is complements and colors the conversation, making it more whole, more real.  To do this takes listening.

Nevertheless speaking must be done. It’s what people expect from leaders. My first goal when I speak is to drive common values and principles, to align thinking and actions, and to motivate effort towards a shared vision.  In other words: be inspiring.  My second goal is to be a sensemaker.

It is the job of the leader to bring order to the whole in order to influence the group to reach their shared vision. This is called sensemaking. A leader must do it well and communicate it well to be a good leader. Lao Tzu said, “What is a wise man’s job, but to make another wise.” A leader’s job is to create wisdom for all. Great communicating requires a humanistic approach, which results in an increase in collective wisdom.