Souba, Wiley W. MD, ScD, MBA; Day, David V. PhD
The turmoil and volatility that have permeated U.S. academic medical centers (AMCs) over the past decade have created an enormous amount of confusion, uncertainty, and anxiety. AMCs have struggled to adapt to fiscal constraints, survive in a competitive marketplace, and successfully carry out their core missions of patient care, research, and education. In the midst of these difficult challenges, faculty and staff have struggled to find meaning and fulfillment in their work.1
During turbulent times, when their most genuine convictions are often tested, most people look to their fundamental values and ideals as the ultimate source of deep-seated purpose and truth when making choices or setting priorities.1,2 They also look to exemplary leaders for guidance—leaders who have developed the moral capacity to judge issues and dilemmas that are not clear-cut. Effective leadership is anchored by an unwavering set of core values that can set an AMC apart by clarifying its beliefs and guiding principles. But core values have a downside. They sometimes limit what the organization can do and constrain how people can behave. Abiding by core values is not always easy because leaders are under constant surveillance. It takes intestinal fortitude to make your values count and those people who will not honor or embrace them have to be addressed.
A cursory examination of the past versus the present demands on AMCs indicates very different sets of underlying core values. In particular, there has been a shift from an emphasis on individual-oriented values (e.g., nonintegrated care, physician led, autonomy) to those that are more collective (e.g., coordinated care, team led, teamwork).3 A primary focus of our study was examining to what extent the values that are espoused by deans/chief executive officers (CEOs) are shared across AMCs. We were also interested in the relationship of those values to deans' underlying implicit theories of leadership, as well as how the values inform their major leadership challenges. In other words, we wanted to learn more about how deans think about leadership and the leadership challenges they face. What are the positive values they espouse? How widely shared are these values among deans? What are the types of complex challenges deans face and how do they or do they not align with commonly espoused values?
We addressed these research questions through semistructured interviews and values Q-sorts with a sample of AMC deans/CEOs. Our primary goals (as reflected in the preceding research questions) were exploratory and descriptive rather than confirmatory and prescriptive. We sought to better understand the most prevalent values espoused by deans/CEOs and their relationship to underlying leadership challenges. We did not intend to predict or prescribe those values or how they might inform the kinds of leadership challenges faced by these leaders.
We collected data from 18 individuals serving as dean of the college of medicine or dean and executive vice president/CEO of an AMC. We chose the participants to include deans from both public (no. = 5) and private (no. = 13) institutions from different geographic regions of the United States and from AMCs that vary considerably in terms of the size of their clinical and research enterprises. The data were collected from September 2003 through June 2004. Seventeen of the individuals in the sample were male and one was African American. Six of those interviewed also served as the health science center's CEO or executive (senior) vice president of health systems. All individuals had similar educational backgrounds and advanced training (e.g., residency). The modal type of medical background was internal medicine (no. = 4), followed by pediatrics (no. = 3), and psychiatry (no. = 3). Two participants claimed primarily research backgrounds and one each specialized in anesthesia, family practice/emergency medicine, hematology, neurology, pathology, and surgery.
In eight of our participants' AMCs, the leadership of the medical school and the teaching hospital was joint and was the responsibility of the dean/CEO (dean/senior vice president for health affairs). In ten institutions, the leadership was separate (separate boards). Five of the 18 AMCs had both full-time and voluntary faculty; in the other 13 all the faculty were full-time. The faculty practice plan fell under the purview of the dean in 13 of 18 institutions.
Eight of the deans were from the Northeast, two from the Midwest, three from the West, and five from the South. Their position tenures as dean ranged from one to 11 years with a median of 5.5 years.
Eleven interviews were conducted in person and the remaining seven interviews were conducted by phone; each interview took approximately 45–60 minutes. Decisions about whether to conduct an in-person or phone interview were made in part by the proximity of the participating dean's medical school to the first author's (WWS) home institution. Prompts were organized around four general dimensions:
▪ history and personal background
▪ leadership challenges (e.g., major challenges and opportunities in the role and how they were addressed)
▪ organizational effectiveness (e.g., primary criteria for evaluating success and effectiveness)
▪ systems forces for leadership in their AMCs (e.g., factors that are perceived to enable or restrain leadership)
The specific questions in the leadership interview protocol are shown in the Appendix. All interviews were transcribed and their content coded using the QSR N6 qualitative data analyses software.4
Before beginning the interview, the interviewer provided the dean with a brief overview and summary of the research project, explaining that the primary goal of the project was to understand how the dean thinks about leadership. The interviewer emphasized that there were no right or wrong answers for the questions being asked. Instead, the interview was an opportunity for the authors to gather data that might help them (and others) better understand what leadership looks like in various AMCs. The interviewer stressed the confidentiality of the interview and pointed out that no individual identities would be associated with any of the interview transcripts. Participants signed written informed consent. All participants agreed to be tape-recorded. The study was approved by the Institutional Review Board of the Penn State Hershey Medical Center.
In addition to the interview, participants were presented with a list of 38 positive leadership values and asked to sort them into nine categories. The instructions requested that participants sort the values (each presented on a 3 × 5 inch index card) into a set category configuration based on how essential the value was for effective leadership in their institutions. The procedure followed a recommended forced grouping protocol in that the sorting configuration adhered to a 1-2-4-7-10-7-4-2-1 normal distribution arrangement.5 Thus, only one leadership value could be placed in the category of “most essential” followed by two values in the “next most essential” down to the ninth category (“least essential”), in which only one value could be placed. Resulting value scores were assigned based on how each participant sorted the respective value. A value placed in the most essential category was scored as 1, those in the next most essential were scored as 2, and so forth to the very least essential value that was scored as 9. Thus, more essential values have lower average scores than the less essential values. Participants interviewed by phone were mailed the Q-sort materials and instructions, and returned the completed task to WWS by mail.
We independently coded interview themes and then compared and combined them following discussion. Although interrater reliability was not formally assessed given the qualitative nature of the presenting themes (i.e., many of the themes were similar in meaning but used different wordings), there was high agreement as to the respective themes presented by the deans' responses. The QSR N6 program was used to code each response by the question posed, organize interview responses, and retrieve them prior to content coding by theme. Each response was subsequently coded with the respective theme(s) that we identified. This procedure follows recommended practice.6 We analyzed the Q-sort data using SPSS software Version 12.0 (SPSS Inc., Chicago, Illinois) to compute descriptive statistics as well as correlational results. Given that the Q-sort results yield only interval-level data, nonparametric correlation coefficients were computed (Spearman's rho).
An overarching purpose of this study was to examine the relationship between the core values that deans considered to be most essential for their leadership and the major leadership challenges that confronted them.
Major complex (leadership) challenges
Interestingly, 14 of the 18 (78%) deans interviewed listed financial dilemmas as the biggest complex challenge their AMCs were facing. We consistently heard deep concerns about the financial struggles involved in successfully recruiting top faculty, investing in new programs, and building new space. With regularity, participants stated concerns about reductions in reimbursement for clinical services rendered, decreases in the National Institute of Health (NIH) pay line, and the need to continuously invest to maintain a contemporary high quality educational curriculum. As one dean remarked, “You know, the number one, two, three, four and five priority here is financial stability and the trustees watch that like hawks.” Another remarked, “All of the issues that I face are money issues and I am sure that is true of every other person in my position nationally.”
The second most common complex challenge was building alignment—11 (61%) deans mentioned this challenge—either structural (e.g., alignment between the medical school and teaching hospital around programmatic development), cultural (e.g., encouraging basic scientists and physicians to collaborate to improve translational research), or role (e.g., cooperation, teamwork among what has historically been parochial, silo-oriented departments). Strategic alignment is what allows leaders to link strategy to vision and goals at all levels of the organization to ensure that everyone is pulling in the same direction.
The third most common complex challenge was staffing problems (six deans [33%]) and the fourth was poor morale (five deans [28%]). The inability to recruit and retain health care workers is a huge problem familiar to every hospital executive. The effects are enormous. The nursing shortage, for example, negatively affects patient quality and safety, leads to an increase in cancellations of elective surgical procedures, reduces the number of staffed beds, and contributes to overcrowded emergency rooms. Staffing problems can lead to burnout, highlighting the interplay between some of these tough problems.
Another challenge articulated by five of the deans was that morale has dwindled over the past years. Although this was due in part to pressure to do more with less, it was also related to workforce shortages and a concern that, in becoming more commercially oriented, some of the fundamental core underpinnings of medicine (e.g., professionalism and compassion) have been de-prioritized.
Coping with complex leadership challenges
An important element of the structured interview involved inquiry into how deans dealt with difficult and often overwhelming challenges. Nine deans (50%) believed open and candid communication to be the single most effective means of addressing complex problems. An important component of this honest dialogue was transparency—the open, bilateral access to information between partners that is essential to building collaboration and facilitating resource exchange, key enablers of systemic leadership.3 This way of thinking about leadership as an organizational capacity is important because understanding leadership as something that is produced and doled out by a person in charge is insufficient in today's complex, turbulent world of academic medicine. Instead, leadership is more often something people create by working together productively.
Difficult people (7 deans [39%]) and micromanagement (3 deans [17%]) were the major restraints to leadership being developed as a systemic force. Every AMC has a few individuals who resist change and attempt to thwart the dean's agenda. Often, these people are chronically and hopelessly unhappy; they may feel passed over and unappreciated. Because the cynicism generated by these individuals can be a powerful contagion, as well as counterproductive to a healthy leadership climate, it is essential to unify those members of the faculty (who are on board) to neutralize these difficult people who will, on a regular basis, try to block key initiatives.
Although the deans we interviewed acknowledged that their jobs had headaches and frustrations, there was, with rare exception, great satisfaction and psychic return involved in being a dean. One of the questions we asked each dean was: What gives your work meaning? The responses were uniformly heartwarming: “A happy faculty, a faculty that wants to come to work,” “The success of the people that I work with,” “The accomplishments of other people,” “We have created some programs that have a real impact on people's lives,” and “It is absolutely the interaction with extraordinary people at all levels, whether students or faculty.” With very few exceptions, the deans found the most fulfilling part of their work to be their ability to make a positive difference in the lives of other people.
The results of the Q-sort exercise provided interesting insights into those values that the participants found most and least essential to their leadership. The values and their descriptive statistics are shown in Table 1. Every dean listed the value of integrity in one of the top four categories. Nine of the 18 deans listed integrity as the single most important value. To put this finding into perspective, the next most essential values across participants were trust and vision. Both of these values were placed in a top-four category by 14 participants (78%). Eleven (61%) placed the more interpersonal values of excellence and teamwork as the next most essential. Values that were generally considered to be least essential for leadership included (with the number and percentage of deans listing it in the bottom four categories in parentheses): loyalty, drive, and change (12 each [67%]), business acumen and institutional reputation (13 each [72%]), authority (14 [78%]), and visibility (15 [83%]). Figure 1 and Figure 2 summarize these overall results.
Of additional interest are the relationships between the key “prototypical” values of AMC leaders. We know that integrity was highly consistent as an espoused value across all participants, but what other values was it related to empirically? Our results indicate that integrity was positively (and significantly, p < .05) related to respect (r = .59), inspiration (r = .59), creating meaning and fulfillment (r = .57), and providing honest feedback (r = .48). It was negatively (and significantly) related to the values of seizing opportunities (r = –.55) and results (r = –.51). The value of vision was positively related to decisive (r = .66), results (r = .63), and seizing opportunities (r = .60). It was negatively related to trust (r = –.59), creating meaning and fulfillment (r = –.57), respect (r = –.56), providing honest feedback (r = –.49), consistency (r = –.48), and caring (r = –.47). The only values that trust were significantly related to was a negative relationship with vision (r = –.59) and with authority (r = –.49). Excellence was not significantly related to any of the other values.
Also of potential interest are the empirical relationships with the more collective-oriented values of building relationships and teamwork, which were consistently considered as highly essential to effective leadership. Building relationships was positively related to change (r = .53), whereas teamwork was negatively related to making tough decisions (r = –.57), seizing opportunities (r = –.53) and authority (r = –.50). Interestingly, the correlation between teamwork and building relationships was only marginally significant (r = .40, p < .10).
In our study, we attempted to gain a deeper understanding of the guiding (espoused) core values of medical school deans and the relationships of those values to their major leadership challenges and their underlying implicit theories of leadership. Attempts were made to interview deans in a variety of different medical schools. We attempted to cut across both public and private medical schools with different governance models, geographical differences, and size of the college of medicine in terms of the clinical enterprise and research portfolio.
Perhaps not surprisingly, the top leadership challenge echoed by 14 (78%) of the deans interviewed concerned financial constraints that limited their ability to grow, recruit, and invest. Yedidia7 reported similar findings in a study published in 1998 that involved open-ended interviews with 22 medical school deans. A decline in resources following an era of abundance was a major cause of problems with unprecedented complexity and urgency in that study. In the face of scarce resources, the organization's strategic vision must be realistic and the need for alignment and collaboration are critical. Weak alignment, be it structural, role, or cultural, was cited as being the second major impediment to getting everyone to play off the same sheet of music in unison, so as to link institutional and departmental strategy and achieve the organization's goals.
It is interesting and perhaps somewhat paradoxical that business acumen was listed as a less essential value, especially given that 78% of the deans listed financial constraints as their major complex leadership challenge. This may appear to be a disconnect but we believe most people equate business acumen with good management skills rather than with leadership expertise. Of note, we did not ask the deans how essential the core values were to solving the complex problems they identified. Rather we asked them how essential these values were to how they thought about leadership in their organization. These questions are different and may explain why business acumen did not emerge as a highly espoused value.
Despite the substantial differences among the deans' institutions, the challenges they faced, and their personalities and leadership styles, they seemed to share a common set of core values that they ranked as most important. Results of Q-sorts on 38 positive leadership values indicated that the one considered most essential across participants was integrity. This finding is consistent with that of researchers who found that integrity was the trait most frequently cited by their sample of senior executives as being highly associated with ethical leadership.8 Traits are dispositional (personality) characteristics that are closely related to the values that are held and espoused by individuals. Our results suggest that AMC deans/CEOs believe that the most essential value for effective leadership is also the one that has been singled out as critical for ethical and authentic leadership. As summarized recently with regard to organizational virtue, integrity has been shown to be associated with higher levels of self-esteem, intimacy, self-regard, and positive effect.9 Additionally, it has been shown to be associated with productive interpersonal relationships, teamwork, participation, and positive organizational climates. These characteristics of ethical leaders are relevant to the deans we interviewed because ideally “authentic leadership behavior … cascade(s) from the very top of organizations down to the newest employee.”10
Although integrity was inversely correlated with the values of seizing opportunities and results, it was positively related to respect, inspiration, and creating meaning and fulfillment. Conceptually, integrity has also been linked to creating meaning at work and in developing meaningful work.11 This type of “meaning making”12 could also be construed as value creation—adding value to organizations. It would be difficult to imagine authentic leadership without integrity, so it is gratifying to see this as the most commonly espoused leadership value, especially when the financial pressures faced by these leaders (as noted in our results) are considered. Without a strong connection to integrity and ethical leadership, a dean might be tempted to take certain financial shortcuts that could undermine the AMC mission in the long run.
The finding that vision was highly ranked as a leadership value may signal the vital importance of setting a clear direction in the face of limited resources and an uncertain future. Strategy is as much about what the AMC decides not to do as it is about what it chooses to do. As asserted by the keynote speaker at a recent joint meeting between the Association of Academic Health Centers and the University HealthSystems Consortium, “It is not acceptable to simply hang on. We cannot accomplish our societal purpose by hanging on …. We must have a clear vision of where we are going, strategic plans to get there, and a willingness to make focused investments that are in the best interest of the whole.”13
What is most interesting about vision is its relationship to other values in this Q-sort exercise. Most people would agree that visionary leadership is necessary for organizational effectiveness, especially those in dynamic and turbulent environments (such as AMCs). There is less consensus, however, on exactly what visionary leadership means or what it looks like. According to the correlations with other values, our sample appears to have associated vision conceptually with more “bottom-line” values such as results, decisiveness, and seizing opportunities. Visionary leadership is negatively related to the more humanistic values of respect, caring, trust, and creating meaning and fulfillment. These findings raise the possibility that terms such as vision and visionary leadership are code for attending primarily to business results and secondarily (or worse) to human needs. More research is needed to further unpack the meaning(s) behind the leadership value of vision.
Of the most essential leadership values, participants included two that could be considered more collective than individual. Specifically, teamwork was seen by over 60% of the participants as being among the most essential leadership values in their respective institutions, and building relationships was noted by half of our sample. Although the correlation between teamwork and building relationships was only marginally significant (p < .10), it does suggest that AMC leaders view teamwork and building relationships as connected. Tying this back to the initial purpose of our study, the wide average endorsement of these values bodes well for the development of shared leadership and building leadership as a property of a living system.3,14 The endorsement also indicates a willingness to promote the importance of sharing power and influence. Future research is needed to determine whether other AMC leaders (e.g., chairs) endorse similar values and, more importantly, whether shared values improve organizational performance.
Values such as integrity, trust, and teamwork can be developed in leaders and we believe this holds continuing promise for the development of positive organizational leadership in AMCs. The practical relevance of coaching future leaders on the importance of getting followers to identify with their values to increase the chances of their message (i.e., vision) being embraced has been reported.15 Because of their positions in health science centers, medical school deans play a vital role in creating the conditions and the climate that will help others make the right choices. In view of the clash that may exist between so-called humanistic values and performance or results-oriented values, this role is absolutely crucial.
We recognize and acknowledge that leaders must go beyond espousing positive values to enacting them in their everyday behavior. Nonetheless, before such values can be enacted they must be endorsed (i.e., thinking is for doing). It has been proposed that organizations exist largely in the mind of their stakeholders and their existence takes the form of implicit leadership theories or what has been called cognitive maps.16 We believe that leadership values offer important signposts in the cognitive maps of top-level leaders. One of our central purposes is to ascertain what are the espoused values of AMC leaders, how widely shared they are across institutional leaders, and whether the values would facilitate the open, transparent, and trusting climate thought necessary for shared leadership to emerge.17
Our study had limitations. Because of the special features of this sample and their unique institutional challenges, we cannot make any claims about the generalizability of our sample or results but we did not propose it as one of our goals. AMCs are unique kinds of institutions facing unique challenges even within the health care industry. Nonetheless, these institutions and their leaders serve a critical role in educating, training, and developing the future leaders of medicine.
It goes without saying that top leaders of AMCs can easily lose their credibility if their actions are inconsistent with the values they espouse. A value means something only if and when people choose to hold it, to live up to it, to make it count. Ours study points out that the complex challenges that confront our AMCs have contributed to the development of a dynamic tension between humanistic values and performance-based core values. The ability to manage that tension in terms of when to prioritize one set of values over the other is an inherent part of a dean's work.
This study was supported by an Association of American Medical Colleges Council of Deans fellowship awarded to Dr. Souba. The authors thank Nancy White for her administrative support on the project.