NEUROGENESIS

Pursuit and Achievement of Leadership: A View from the Top Nina F. Schor, MD, PhD There is no single formula for successful leadership or unique phenotype for successful leaders. There are, however, unifying principles and approaches that enhance the likelihood of success and fulfillment in leadership roles. Here we discuss the requirements for leadership positions in neurology and those personal qualities, management styles, priorities, and philosophical approaches that are likely to make individuals successful in such positions that serve to inform, mentor, and encourage the next generation of leaders in neurology. ANN NEUROL 2014;76:784–788

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here is a phase of one’s academic career in which those who are in the trenches staffing clinics and hospital units; performing research in the laboratory, clinic, or community; or teaching and mentoring trainees in the classroom or “real world” setting are seen as heroes, and the word “administrator” is used in the pejorative sense. At some point, if one is really lucky, one works with an administrator who sees that position as a means to a greater end—a way to mentor and guide, to champion the careers of others, and to realize a broad vision. At that point one realizes that those who were called administrators in the pejorative sense were not particularly good administrators, and that administration, like anything else worth doing, involves a set of skills and aptitudes that must be learned, cultivated, and practiced to be mastered and used to worthy effect. One recent exploration of the roles of leaders in medicine has pointed to the increasing emphasis on revenue generation, patient throughput and satisfaction, care quality, and outcomes measures, and the decreasing availability of resources in every arena as factors that have changed the roles of physician leaders and the desirability of such positions to those most qualified to take them. Such an analysis loses sight of the overarching vision that should be the motivation for assuming positions of leadership. In this regard, Chervenak et al. remind us of the 4 cardinal virtues that should guide physician leadership: self-effacement, self-sacrifice, compassion, and integrity.1 To be sure, it is not easy to find this ideal model embod-

ied in people who genuinely want to implement it to achieve a worthy overarching and innovative mission. In today’s real world of shrinking means and growing demands, the concrete and frequently individual nature of these demands can divert one’s attention from the big picture vision on which a leader’s energies should focus. This NeuroGenesis feature explores the reasons to consider pursuit of a leadership position, the best practices that make one an effective leader, and the ways in which one can continue to grow professionally and personally while implementing a vision that facilitates the professional and personal growth of others and the elaboration of a whole that is greater than the sum of its human parts.

Thinking about the Pursuit of Leadership Positions It has been said that “Being a department chair is a halftime job. Unfortunately, it’s every other minute.” Leadership of any kind means that everyone else’s problems become your problem and your own personal passions take at least a temporary backseat to what is good and right for the entity and people you lead. So why would anyone agree to take on a leadership position, especially when being a neurological clinician, scientist, or educator means seeing something new, learning something new, and trying something new each and every day? Professional fulfillment comes in many forms, but it would seem that, in neurology, it can come without taking on

View this article online at wileyonlinelibrary.com. DOI: 10.1002/ana.24290 Received Sep 8, 2014, and in revised form Sep 15, 2014. Accepted for publication Sep 28, 2014. From the Departments of Pediatrics, Neurology, and Neurobiology & Anatomy, University of Rochester School of Medicine and Dentistry, Rochester, NY

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everyone else’s problems. What should make one consider taking on an administrative leadership position? There are 4 basic reasons to become a leader. First, you might want to pursue this course if you have programmatic, rather than tactical, ideas and want to implement them. One way to do this is to become the leader of a group and to delegate to the members of that group responsibility for components of the program you hope to build. You provide the vision and the glue that holds the components together, motivates the implementers of the components, and oversees quality control. Second, if you are a “big picture” person rather than a detail person, you may want to consider becoming an administrative leader. The job of a leader is to sit at 30,000 feet and see the overarching panorama. The leader builds the synergies that come from juxtaposing components who ordinarily might not even know of each other’s existence. Elaborating and managing the overarching vision allows one to see connections that are not otherwise visible. Third, as a leader of progressively higher-level and more complex organizations and groups, one is charged with mentoring successively more advanced professionals. As an assistant professor or a new community office practitioner, one typically mentors undergraduate or medical students in the clinic or laboratory and the patients and families who frequent one’s practice. As a division chief, one mentors fellows and faculty committed to and skilled in neurology and neuroscience and often with a sub-subspecialty that makes them a unique contributor to the team led by the division chief. As a department chair, one mentors division chiefs who have circumscribed visions of their own that contribute in aggregate to one’s vision for the department as a whole. This pyramidal system means that climbing the administrative ladder affords a series of mentoring relationships with colleagues whose skill and knowledge are closer and closer in level and more and more complementary in content to one’s own. It becomes harder and harder to tell the mentor from the mentee, and both learn more and more from one another. Finally, being a leader of a team enables one to impact things across a broader topical spectrum than could be done with one’s own narrower skill set and expertise. Put simply, one can accomplish more with a larger breadth than would be possible as an individual.

Guiding Principles of Leadership There are several guiding principles of effective leadership in general. All of these apply to leadership positions in neurology, whether in academia, community-based practice, industry, or governmental and public service. After December 2014

all, people are people. But as with any field, there are challenges and interpersonal imperatives that are unique, perhaps, to neurology. This is what makes leadership both difficult and fun. Creativity is helpful, humility is critical, and cognizance of institutional history and willingness to acknowledge and/or change it are key. Here is a point-by-point accounting of some of the precepts that make for successful leadership, along with some neurology-specific examples and caveats. Listen Well and Read between the Lines If you have spent any time as a clinical neurologist, you are probably already an expert at doing this with your patients. One might think this would make all neurologists outstanding leaders. But we tend not to do this as well when interacting with one another or with our students and staff. Perhaps this is because it is “work,” and we work with our patients but relax and do what is most fun for us with our students, staff, and fellow neurologists. The best leaders are working even when they are theoretically not working. This realization is sometimes what keeps some from deciding to pursue leadership positions. In any case, as a leader, in interacting with those whom you lead, it is critical that you consciously and deliberately take note of the context, the possible secondary agenda, and the body- and voice-language with which you are approached. This sounds at face value a little like being suspicious or paranoid. If it becomes such, that is a problem! It is merely a sensitivity to the motivation and intent of one’s colleagues and to one’s own potential biases and preconceived notions that adds to the likelihood of success. Just as when a patient comes to see you in your office, when a colleague comes to see you, you should think, “Why? Why now? Why with this approach?” Most of the time the answer is very straightforward and the conversation is just that—a conversation. But what separates the outstanding leader from the merely satisfactory one is anticipatory attention to the 1% or less of the time when something not quite straightforward is involved. Learn from Everyone and Everything In recent years, the concept of a mentor has become a formal, often assigned or designated one. Students are assigned a mentor. Residents and fellows choose a mentor and a mentoring committee. Faculty and community physicians serve as mentors. Mentoring awards and curricula abound. As a neurologist of my generation, when I think of my own mentors, it strikes me that many of them would never have used that word to characterize our relationship. They just did what they did; I was an observer, 785

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a cataloguer of what I would or would not someday make my own approach. There were those whose approach to hypothesis generation, organization, management, clinical neurology, or delivering bad news was consistent with what I ultimately wanted to be and achieve. I learned immensely from them and, after initial imitation, then modified their approach to take the kind of ownership of it that made it comfortable for and consistent with me. There were those whose approach made me say, “I will never do that in that way.” I learned immensely from them, too. They were all mentors. Just as even the most wonderful neurology or neuroscience position requires one’s occasional involvement in something that is mission-critical but not fun, so it is with leadership positions of any sort. These situations can be enormously instructive, both about the leadership style of those who are responsible for them (Take notes!) and, through awareness of one’s reaction to them, about one’s own tolerances, leadership style, and priorities. Although it is true that, just like mentorship, lessons and courses in leadership have become very formal and popular, every experience you have is a lesson in this regard if you pay attention. Value All Components and Contributions The history of neurological leadership is filled with leaders who apparently favor one group or person over another and people who do not feel appreciated by their leaders. There are, to be sure, always “contributions” that work at cross-purposes to one’s vision and people who, despite considerable efforts, do not or choose not to get it. Clearly, this cannot be applauded or even tolerated. But it is critically important, as a leader, to recognize that, because one becomes a leader to make an impact broader and deeper than what one can do alone within one’s area of passion and expertise, not everyone in one’s charge does what one does the way one would do it. Even those who seek to achieve the same vision as you may choose to get there by a different path. As a leader, you are charged with making a whole that is greater than the arithmetic sum of its parts. You must first make your vision and expectations in every arena clear and consistent so people can find their niche within that framework. Then, as each of your colleagues begins to define what role he or she will play in operationalizing that vision, you must both value every genuine contribution to the effort and help the square pegs who do not fit into round holes redefine themselves in a way that makes them both successful and solid contributors to your vision. You will not succeed in each and every case, for many different reasons. You may have to clear away those who insist on working at cross-purposes 786

to your vision. You may encounter those who insist, despite your guidance, on working in areas in which their skill set, passion, and zone of excellence do not sit. But all of those who bring something positive to the table must understand and know that you appreciate them and their contributions. Thought without Action Is Useless Neurologists and neuroscientists are great thinkers. We have among us great philosophers, ethicists, applied mathematicians and physicists, genome sequencers, diagnosticians, and lecturers. As wonderful and critically necessary as creative ideas and solutions are, they are just a beginning. Without action, without operationalization, they are not worth much to the people one leads. The same is true for the workforce that reports to a leader. Celebrate the grant funding, but then get to work, because a grant is a means to an end. It is one thing to prepare a new electronic medical record template, but quite another to put it into action and revisit its utility every few months after initial deployment. Without follow-through, your workforce will anoint you as just another talking head. Action without Thought Is Worse As a leader, if your values are not transparent, if your vision is not consistent, and if your actions are not predictable, you will lose your workforce. This does not mean you air everything publicly in real time, nor does it mean that you always and only take the conventional path. But engendering trust is a big part of leadership, and trust is born partly of a sense of thoughtfulness. One’s leadership must be based on principles, and one’s strategic vision must be implemented through publicly elaborated and consistently applied goals and objectives. Development Is Forever The day you truly believe you have learned it all and convey that to your colleagues is the day your term as a leader is over. Leadership means that whatever you are today is not what you will become, and effective leadership sends that message loud and clear to those around it. This means that humility, the capacity to learn from those you lead, and the ability to say, “I was wrong” are assets, not liabilities or evidence of weakness. If It Is Not Funny, You Die Every leader will tell you about the importance of prioritization and the imperative that one not “sweat the small stuff.” How else would one get anything substantive done? But at least in medicine, and perhaps particularly in neurology, where the functions affected most in our patients are those most needed for activities of daily Volume 76, No. 6

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TABLE 1. Small Stuff You Are Forced to Sweat in Academic Neurology

Budgets Internal rivalries and politics Being at the table for your constituency (meetings, meetings, and more meetings) Recruitment and retention Unproductive faculty, trainees, staff Counterproductive faculty, trainees, staff Outmoded but historically beloved meetings, procedures, priorities, faculty, staff (dealing with sentimental value) Patient, family, and community personal requests and demands Facilities Fundraising Interactions with the media

living, there is an awful lot of small stuff not to sweat. Just the volume of it all is enough to drive one insane! (See the Table 1 for an incomplete list of necessary small stuff in academic neurology administration.) That is why I tell my midlevel faculty who aspire to administrative posts, “If you look in the mirror and can’t laugh at the person who looks back at you, the ballgame is over.” Laugh. A lot. Find time to be amused. Find other leaders with whom you can commiserate. Whatever else you do, do not lose your sense of humor and do not take yourself or your charge too seriously. Sweat Is Not Blood Although every leader feels compelled every once in a while to sweat what is undoubtedly small stuff, separating that chaff from the wheat and remembering at those moments why you wanted to be a leader can be critical. Do not let yourself be overwhelmed by a leadership role that requires more kinds of skills than any one person has and more hours than exist in the day. Surround yourself with people you trust who have skill sets that complement rather than duplicate your own. In choosing the fraction of the small stuff you will sweat, make certain it is that fraction that is driven by or will get you closer to the big stuff. No matter how wonderful a leader you are, you and your judgment will be challenged from time to time. Be a straight shooter and take and investigate all criticisms seriously. In criticizing or questioning the judgDecember 2014

ment or actions of those in your charge, always remember that dirty laundry should not be aired outside. In your office, behind closed doors, one on one, you should be a mentor, a disciplinarian, a critic, a challenging professional parent. In the hallways and communities around you, you must be an advocate and champion for the collective mission and vision of those you lead. You may, as a leader, need to change the culture of your organization or group. Any neurologist can tell you that changing the mindset of a thinking brain is a difficult task! Rarely, this needs to be done emergently. The people who instigate and enact this urgent change are “change agents” who sometimes may self-destruct in the process of making the organization much better. Most of the time, however, as hard as it is to be patient, change can be made to happen over time. It requires a constant and consistent effort. It requires convincing others that your idea was theirs in the first place, and then thanking them for coming up with an idea that you yourself never could have. It requires the kind of leader who educates, gives the students credit, and swallows his or her personal pride, but it produces durable change bought into by the participants.

Becoming a Leader A British study looked at those organizational features that most facilitated innovation in a “bureaucratic primary care organization.” The authors list these characteristics as: (1) clear structures and a vision for corporate and clinical governance; (2) multiple opportunities for people to reflect and learn at all levels of the organization, and connections between these "learning spaces"; (3) both clinicians and managers in leadership roles that encourage participation; (4) the right timing for an initiative and its adaptation to the local context; and (5) external facilitation that provides opportunities for people to make sense of their experiences.2 This list is an instructive one for any field of medicine and might be recast as a list of imperatives for the leaders of such organizations. Analogous lists have served as the template for mentoring sessions for midlevel faculty at academic medical centers to allow them to decide whether and how to develop an administrative leadership career.3 So what does a leader do that ensures his or her success and achieves what it takes to forge a successful organizational environment? There is no uniform implementation formula, no one size that fits all. But 6 specific aims will get you most of the way there: 1. Set the vision and the tone. Consistency, clarity, and a view of the big picture go a long way toward getting others to enthusiastically implement your vision. 787

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2. Educate and empower others. The leader’s job is to ensure that others have the tools they need to implement their component of the big picture plan and integrate it with the other components. 3. Tell their stories to the world. The person who starts every sentence with the word “I” should not become a leader of others. 4. Give credit where credit is due. The currency by which a leader is judged is the achievements of those in his or her charge and the vision those achievements allow the organization as a whole to realize. 5. Set the bar high for a standing ovation. Challenge your workforce and your trainees. Expect them to do you proud. 6. Set the bar low for respect and encouragement. Everyone who contributes anything to realizing your vision deserves thanks. Everyone who is a member of your team deserves to be treated with respect and encouraged to realize his or her professional dreams. There is no greater honor and privilege in any field than to be chosen a leader by one’s colleagues. This is all the more true when one’s colleagues are the dedicated, creative, analytical, and compassionate people who call themselves neurologists and neuroscientists. Being a leader in the neurology community is to mentor, champion, and represent the hopes of patients and families afflicted by neurological disorders and the passions of students, trainees, physicians, and scientists who work to

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understand, treat, and prevent their suffering. It does not get much better than that.

Acknowledgment I thank the faculty, staff, and trainees of the Division of Child Neurology at the University of Pittsburgh School of Medicine and the Department of Pediatrics at the University of Rochester School of Medicine and Dentistry, and the members of the Child Neurology Society who gave me the privilege of serving as their leader.

Authorship The ideas, words, and organization of this article are solely those of Dr Nina F. Schor.

Potential Conflicts of Interest Nothing to report.

References 1.

Chervenak FA, McCullough LB, Brent RL. The professional responsibility model of physician leadership. Am J Obstet Gynecol 2013; 208:97–101.

2.

Thomas P, McDonnell J, McCulloch J, et al. Increasing capacity for innovation in bureaucratic primary care organizations: a whole system participatory action research project. Ann Fam Med 2005;3:312–317.

3.

Schor NF, Guillet R, McAnarney ER. Anticipatory guidance as a principle of faculty development: managing transition and change. Acad Med 2011;86:1235–1240.

Volume 76, No. 6

Pursuit and achievement of leadership: a view from the top.

There is no single formula for successful leadership or unique phenotype for successful leaders. There are, however, unifying principles and approache...
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