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Perspective: A New Model of Leadership Performance in Health Care

Souba, Wiley MD, ScD, MBA

doi: 10.1097/ACM.0b013e31822c0385

Current leadership models are based largely on concepts and explanations, which provide limited access to the being and actions of an effective leader in health care. Rather than teaching leadership from a theoretical vantage point, the ontological perspective teaches leadership as it is lived and experienced. When one exercises leadership “as lived,” concurrently informed by theories, one performs at one's best. A distinctive feature of the ontological approach resides in its capacity to disclose human ways of being and acting that limit our freedom to lead effectively as our natural self-expression. Ontological leadership maintains that our worldviews and mental maps affect the way we lead and are shaped by and accessible through language—hence, to lead more effectively, mastery of a new conversational domain of leadership is required. This emerging model of leadership performance reveals that (1) our actions as leaders are correlated with the way in which the leadership situation we are dealing with occurs for us, and (2) this “occurring” is shaped by the context we bring to that situation. Master leaders use language to recontextualize their leadership challenges so that their naturally correlated ways of being and acting can emerge, resulting in effective leadership. When leaders linguistically unveil limiting contexts, they are freed up to create new contexts that shift the way leadership challenges occur for them. This provides leaders—physicians, scientists, educators, executives—with new opportunity sets (previously unavailable) for exercising exemplary leadership. The ontological approach to leadership offers a powerful framework for tackling health care's toughest challenges.

Dr. Souba is vice president for health affairs and dean, Dartmouth Medical School, Hanover, New Hampshire.

Correspondence should be addressed to Dr. Souba, 1 Rope Ferry, Hanover, NH 03755; e-mail:

First published online August 24, 2011

There is broad agreement that our health care system is not working effectively and that a more functional model of leadership performance is essential for meaningful reform. Because current leadership models are based largely on concepts and explanations, they provide limited as-lived access to ways of exercising effective leadership in the real world, in real time and with real results. For example, knowing that effective leaders are authentic does not automatically make one behave authentically. Or, knowing that the best leaders are trustworthy does not instinctively make one act in a trustworthy manner. Effective leadership does not come from knowledge about what leaders do, or from emulating the styles of famous leaders, or from memorizing some “five easy steps to leadership” monograph. Theories alone do not impart what is required to be a leader, much as textbooks do not fully teach what is essential for being a physician. Knowing is not enough.

In addition, the lack of a functional taxonomy precludes a common, coherent, and functional structure to the way we talk about and make sense of the phenomenon called leadership.1 Moreover, our propensity to perceive leadership as being about a charismatic figure—who, through innovative visioning (knowing) and determined execution (doing), solves problems—is too one-dimensional and too superficial.2 It overlooks that the actions of leadership match being a leader.3 And, it leads us to assume that leadership belongs to an elite few who somehow wound up with what it takes to lead, while the rest of us wound up bereft.

As opposed to teaching leadership in health care from a theoretical perspective, in this essay, I propound an ontological orientation. This approach is unique because it provides action-focused access to human nature and the way it functions.4 Action-focused access to leadership refers to access that results in concrete positive actions. Said metaphorically, action-focused access allows leaders get their head around the essence of leadership and their arms around the way it is exercised. It deals with leadership from the perspective of the way it is lived and experienced in the first person as opposed to any theory or explanation. Inside this as-lived experience is where one's natural self-expression lives; thus, access to the as-lived experience is critical if one is to lead masterfully. When one is exercising effective leadership as lived as one's natural self-expression, one is functioning at one's best (contrast the aplomb and ease that innately accompany leading as one's natural self-expression with the clumsiness and artificiality of leading from a set of theories or from attempting to copy a list of personality attributes).

An ontological orientation also maintains that our leadership worldviews are constituted by and accessible through language.5 I contend, however, that the everyday language of leadership is insufficient for mastering what is required to be an expert leader and for the exercise of masterful leadership. I propose that leading expertly requires mastery of a new language of leadership, one that complements the prevailing language of leadership. What is created by this new language can provide physicians, scholars, educators, and managers with new perspectives and opportunity sets for tackling health care's most difficult challenges.

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Ontology, Leadership, and Language

The ontological perspective

Ontology (ontos is the Greek word for being) is the field of philosophy that studies questions like “When someone is being a leader, what is the nature and essence of that being?” (For a fuller explanation, see Box 1.) Phenomenology is the branch of ontology that deals with the way things (e.g., a leadership challenge) occur for us in our experience and the meanings they have in our experience.6 More precisely, phenomenological ontology studies leadership as a first-person, as-lived (or “lived through”) experience as opposed to a set of third-person theories or concepts. For example, when a master surgeon is closing a skin incision, he or she does not perform the act of suturing from some theoretical perspective. The surgeon does not say to him- or herself when introducing the needle into the skin, “I will apply this much force for this long and at this angle.” The physics of suturing, which could be described mathematically in terms of torques, tissue resistance, and vectors, never shows up for the master surgeon as such. Rather, the surgeon sutures to match the way in which he or she lives it (i.e., as the surgeon accesses his or her as-lived surgical experience) and as a correlate of how closing the incision occurs for him or her. It is as if the surgeon is “entangled” in a dance with the surgical procedure itself.

Box 1

Box 1

In contrast, the surgical intern, as a novice, “operates” based on a set of third-person concepts and explanations (and, as such, is not technically adept). To become a master, the intern must learn to experience firsthand the application of theories and knowledge “in action” as lived, as one's natural self-expression. This learning involves a private reflective conversation, a kind of internal discourse of questioning and answering, during which the learner questions and reinterprets inside of the lived experience. While the process hones one's actions, it fundamentally shapes one's way of being, which is the ontological basis for what leaders know and do.3 It is this as-lived perspective that gives one access to the source of performance. One's actions (incising, dissecting, suturing, tying) and the occurring (how the operative procedure occurs for the surgeon) always go together: They are interrelated as naturally, necessarily, closely connected, and mutually arising correlates of each other.4

Most approaches to leadership development emphasize the personal attributes and skills that distinguish effective leaders from ineffective leaders. This prevailing methodology is predicated on the assumption that inculcating people with specific characteristics will make them effective leaders. In other words, effective leadership is about certain behaviors and abilities, and individuals who learn them will become competent leaders. The difficulty with this approach is that one does not inherently and automatically acquire (as one might acquire immunity to a disease) the particular leadership behaviors (e.g., committed, self-aware, empathetic) that one might be deficient in or lacking.

An ontological perspective is unique because it provides those of us who are leaders with access to the true source of leadership performance.4 It stresses the role of context in shaping the way in which any leadership challenge occurs for us and the importance of shifting certain of our prevailing (yet hidden) contexts so that we can exercise more effective leadership. Many of the situations (content) we deal with in health care are unalterable (e.g., decreasing reimbursement, a flat National Institutes of Health pay line, increased provider risk), but we can alter the point of view (context) we bring to these daunting challenges so that they occur for us as workable rather than unworkable. As I will discuss, this translates into new possibilities for exercising effective leadership.

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The objective world and the occurring world

When we talk about leadership challenges in health care, it is important to differentiate between the so-called objective world (people, conversations, and ourselves, unbiased by our perceptions of them) and what can be termed the occurring world (people, conversations, and ourselves as we perceive they occur for us). Each person's life is, in a sense, one big, ongoing, concatenated event made up of a series of endless occurrings (i.e., the way in which the moment-to-moment situations we are dealing with occur for us). We generally assume that what we perceive with our five senses is the reality that is truly, objectively “out there” in the world, but what we actually perceive is the so-called occurring world. Peter Russell7 explains:

It is important to distinguish between two ways in which we use the word “reality.” There is the reality we experience, our image of reality; and there is the underlying reality that has given rise to this experience…. The reality I experience, the reality generated in my brain, is a relative reality. It is relative to my point of view, my past experience, my human senses and my human brain.

From a neuroscience perspective, what we mean by occur corresponds to that which is generated by the particular activated neural networks in the brain that produce the experiential perceptions—via our senses—that are projected into the external world. While we can confidently accept as true that there is an objective reality, what actually shows up for us is a reality generated by our brains. Because our brains are not identical and our life encounters are not the same, we each experience and respond to the world differently. Understandably, each person's worldviews and mental maps (homes of our blind spots and filters) are different from those of other people, and, predictably, they sometimes clash. This conflict is normal; it is just part of being human and interacting with other humans.

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The essential role of language

Because we are humans, the world that occurs for us is a world that lives in language.5 In other words, much of what we happen to be dealing with moment-to-moment has a connection to language, which affects the way in which what we are dealing with occurs for us. If I label the situation I am dealing with as “hopeless,” my way of being and acting will convey hopelessness. Van Manen8 stresses “that lived experience is soaked through with language. We are able to recall and reflect on experiences thanks to language. Human experience is only possible because we have language.” “Language is the house of Being,” wrote Heidegger,9 by which he meant that our access to the world, and whatever shows up within the world, is structured by language. Much of the time we think and we feel by using words. Human being means “human being-in-the-world,” and our understanding of the world (objects, others, and ourselves) is shaped by and accessible in language (talking, listening, reading, self-talk, thinking).10–12

Heidegger's pupil, Hans-George Gadamer,13 describes language as “the medium in which substantive understanding and agreement take place between two people.” Problems cannot be communicated or tackled without the aid of language. We are always and necessarily coordinating and negotiating the way we manage our meanings with other people.14 Gadamer13 (p440) also claims that language constitutes our worldviews:

[L]anguage has no independent life apart from the world that comes to language within it. Not only is the world world only insofar as it comes into language, but language, too, has its real being only in the fact that the world is presented in it.

Clearly, language is not a replacement for intuition. There is a difference between reading about a feeling of danger and actually sensing it. Yet, we always stand within language, even when we try to talk about phenomena (e.g., love, leadership, consciousness) that are difficult to describe. When we try to understand what is outside of language, we have to use language to do so. Thus, although there are things in our consciousness that surely exist independent of language, the only way we can talk about them—however ill defined they may be—is with language. More to the point, the way in which any health care leadership challenge we are dealing with occurs for us is through language (i.e., what is spoken, unspoken, heard, unsaid but communicated thought). Because these challenges are shaped by and available for interpretation through language, we need a way of speaking that grants us action-focused access to leading expertly as our natural self-expression.

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Conversational Domains

Certain individuals seem to excel, almost effortlessly, in their particular field of interest (e.g., translational science, physical diagnosis, medical student education). They are able to solve difficult research problems, complex patient care dilemmas, and curricular challenges with curious, if not incredible, ease. We often cannot put our finger on exactly what it is that makes these people so effective, but we are intrigued nonetheless. We tend to believe that they are born with something special that makes them unique or unusually insightful. Actually, what allows such people to be so effective is that they have mastered the conversational domain necessary to perform exceptionally in their particular field of interest. This mastery allows them to perceive and deal with problems in a unique manner.

The term conversational domain means—for example, in the case of medicine—the network of discipline-related terms that form the special linguistic domain through which a physician perceives, comprehends, and interacts with his or her patient's body, history, illness, and suffering.3,4 This specific conversational domain is required in order to be a master physician and for the expert practice of medicine. Mastery of the conversational domain particular to any discipline—biomedical informatics, astrophysics, quantum mechanics, etc.—is essential if one is to effectively communicate, perform, and innovate in that particular domain. Swales15 explains that conversational domains are characterized by a “suitable degree of relevant content and ‘discoursal’ expertise” that includes “lexical items puzzling to outsiders.”

A molecular epidemiologist, for example, becomes a master by mastering the conversational domain of molecular epidemiology. Mastery allows him or her to observe, interpret, understand, and interact with the world of molecular epidemiology through a set of specialized terms (e.g., DNA adducts, genome-wide association studies, genetic linkage, biomarkers, polymorphic variants) that are networked together in a specific way to form the linguistic domain of the world of molecular epidemiology. Similarly, a structural biologist becomes a master by observing, interpreting, understanding, and interacting with the world of structural biology through a set of specialized terms (e.g., macromolecular crystallography, hydrophobicity analysis, tertiary structure, laser spectroscopy) that are networked together in a specific way to form the linguistic domain of the world of structural biology for a master structural biologist. In other words, the source of being extraordinary in any domain is mastery of the unique conversational domain that gives one access to that domain.

Conversational domains, once mastered, afford considerable power. Experts could not achieve, communicate, or create new knowledge in their particular domains of expertise without having mastered their domains' language because the specialized language is what gives them action-focused access. Mastery, then, is a product of having sufficient as-lived experiences to master a specialized conversational domain from which the master observes, interprets, understands, and interacts with his or her particular knowledge domain. For example, medical school and residency are as-lived experiences that are intended to enable physicians to become masters of the conversational domain of medicine and often a particular subdomain (cardiology, nephrology, neonatology, etc.).

Conversational domains can overlap and frequently do—for example, physics and mathematics share domains. More recently, the field of bioengineering was born when the overlap between the domains of medicine and engineering was recognized. Over the past few decades, the conversational domain of bioengineering has become more sophisticated as researchers have shared their findings, engaged in dialogue, and developed a shared language that functions as a kind of lens (a context) that grants improved action-focused access to the world of bioengineering. This improved access, which enables new insights and novel distinctions that further advance the field, is the result of a more refined set of specialized terms that are linked together to form the linguistic domain of the world of bioengineering. This process of mastering a conversational domain such that it “uses” the master by providing a context (a way of perceiving, interpreting, and relating to the corresponding knowledge domain) is key to performance and innovation whether one is a programmer, an electrician, or a doctor.

The emerging conversational domain of leadership overlaps powerfully with the domains of ontology, phenomenology, linguistics, and neuroscience.3–5 In this essay, I have introduced terminology (see Table 1 for examples) to create a new conversational domain that allows for the expert practice of leadership in health care as the leader's natural self-expression.

Table 1

Table 1

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The Power of Context

When we say that leadership always happens within a context, we take the word context to mean a set of fundamental but often hidden frames of reference and assumptions that shape the way any situation occurs for that leader.16,17 Context shapes the way we interpret (make sense of) any leadership challenge or situation we are dealing with. Context mastery is about “seeing” differently, such that the intimidating situations we might be dealing with in our day-to-day work occur for us as confrontable and resolvable. Alan Webber18 writes,

No matter how many raw facts you know, they're only as valuable as the context within which you put them. That's why context is more important than content and always will be. Information is a commodity but context creates value.

In other words, no matter how much leaders know, their effectiveness as leaders is only as valuable as the context that uses them to leverage their know-how and know-what. Mey19 articulates this notion succinctly:

[T]he reason why “facts” constitute such an ineluctable blind alley of our thinking about communication is that we are neglecting not the facts themselves, but their context…. A context with which we can identify will make the fact occurring in that context into much more than just “information”…. A fact that disrupts this context is much more prominent than some other fact that … we cannot relate to because it does not belong to our immediate context.

Many leaders in academic medicine spend much of their time in the domain of content, where issues are understandable, strategies are familiar, and solutions seem straightforward. But complex problems cannot be tackled by solely addressing content; they must be situated within an appropriate context (frame of reference) to provide a basis for action. Good leaders learn the content (concepts, theories, explanations); great leaders also master the contextual dimensions of leadership.

In all human activities and undertakings, context is decisive (whatever occurs for you—in the sense of the occurring world—occurs inside of your context). Inside of our contexts is a set of seemingly rational assumptions, preconceptions, and beliefs that are usually unarticulated and thus concealed. Our ways of being, thinking, speaking, and acting reflect and reveal the context(s) within which and from which we live our lives. That is, the hidden contexts from which we live determine what we see and what we do not see, what we consider and what we overlook, what we are able to do and what seems beyond our reach. If I live my life within a context that says, “I always get dealt a bad hand in life,” I will think, speak, and behave from a position of self-pity and “poor me.” Part of being human is lugging around these invalid, encumbering contexts, often for a long time. To be a master leader involves identifying such contexts. And these patterns, assumptions, and frames of reference are embedded in language, as I will soon illustrate.

Once our contexts become etched into our mental maps, there is often a future that has already been written about whatever we have to deal with. Although this future is seldom talked about, it is the context in which and from which people try to create change. For example, a few decades ago, if someone had said that the long hours and intimidation typical of surgical residencies were inappropriate, it would have been rejected out of hand because people's context for superb surgical training was consistent with a 100-hour workweek and an autocratic department chair. When the inadvertent consequences of such long work hours made their way into the public arena, new possibilities for residency training entered the conversational space. Any such new “realm of possibility” is always generated in and by language, as a linguistic construct. Until a new realm of possibility is created, we are stuck with the prevailing context. About 15 years ago, the concept of duty hours was created as a realm of possibility. Before then, the notion of duty hours did not occur to the extent needed to induce change. A linguistic construct can be thought of as a conversational domain that generates a realm of possibility that at some point winds up being named.4

I am emphasizing the importance of context because it is not only powerful and decisive but also largely invisible. Duranti and Goodwin20 note that context and content differ in their “perceptual salience”; content “is regarded as the official focus of the participants' attention, while features of the context are not highlighted in this way, but instead treated as background phenomena.” Accordingly, context has to be “unconcealed,” a process that involves revealing the listenings (see the definition of already-always-listening in Table 1) that make up the context. For example, the physician who learned as a child that shouting got him or her what he or she wanted must learn to understand the situations that have resulted in that particular way of being and acting that persists in the operating room or on the wards. This is indeed agonizing work, as that reflex-like behavior stems from a listening that has become deeply engrained.

Because we create contexts (in language), we can “uncreate” them and rewrite what is otherwise almost certainly a SO-SO (same ol', same ol') future.17 This creates the space to create and master a new context, one that positions us to deal more effectively with what must be dealt with. Good leadership is an exercise in mastering a new context via language. But doing so is difficult: What we create in language uses us. Heidegger reminds us that “man acts as though he were the shaper and master of language, while in fact language remains the master of man.”11 Language and leadership are inextricably linked, and they are always contextual. Context and language work “reflexively”; while context determines language, language also defines context; words are not only labels for an already-existing reality but also “instruments for defining the situations in which speakers co-construct their context.”20 Context always shapes the way a situation occurs for us, and our way of being and acting in that situation will be naturally correlated with the situation occurring for us as context has shaped it.4

The model of leadership performance proposed in this article is designed to make people aware of their limiting contexts and to recognize that they need not be ruled by those contexts.3–5,16 For example, the language of change is often embedded in contexts of loss and fear.21 These contexts often create the perception that whatever we are dealing with is formidable, too risky to take on, and unworkable. They dissuade and deter us from taking on the challenge at hand; as a consequence, we avoid the issues, dodge the crucial conversations, sidestep the work that needs to get done, and pretend the challenge will go away on its own. When these contexts become apparent and known, we can begin to see the inadvertent process by which they were assembled and the degree to which they govern our everyday lives.16,17 We are left, possibly for the first time, with a choice about who we are and who we can be, separate from these contexts.

Thus, the power of the ontological approach to leadership lies in its ability to disclose the hidden contexts that shape our ways of being (and acting) and limit our freedom to be leaders and to exercise leadership effectively as our natural self-expression. The focus is on those ontological factors that act to constrain and distort our freedom to listen authentically, think strategically, innovate, and build high-performing cultures. A central principle of an ontological approach to leadership in health care is that leaders are more effective (and more personally fulfilled) when they are not limited by their unchallenged assumptions, concealed frames of reference, and taken-for-granted worldviews. In the presence of these limitations, it is impossible to lead as one's natural self-expression.

Each leader wants to perform at his or her best. When leaders are aware of—and thus less constrained by—their ontological handcuffs, whatever leadership challenge they are dealing with occurs for them as it actually is (to the extent humanly possible), and the correlation between what is occurring for them and their way of being and acting results naturally in each leader's personal best for dealing with the challenge.4 In other words, the conditions exist such that leaders can lead as their natural self-expression and be at the top of their game.

A new ontology—a specialized conversational domain—for leadership is slowly emerging.3,4,17 Such a distinct, coherent realm is required because an ontological approach to leadership maintains that the occurring world (the world as it occurs for us, which I described earlier) is a world that is sometimes constituted in language, and when it is not, it is at least colored and shaped by language and is invariably accessible through language.4 Because we have jurisdiction over what we say, creating for ourselves what it is to be a leader and what it is to exercise leadership effectively entails mastery of the conversational domain of leadership.4,5 This new conversational domain is just that—it is new, so it is, at first, foreign and somewhat awkward. However, on mastering this linguistic domain, it “uses us,” much as the conversational domain of medicine uses a physician to care for his or her patient. In so doing, limiting contexts become exposed and new opportunity sets (new “clearings,” akin to what one might encounter in a forest) for being and action become available, which enable the realization of a future that would otherwise only happen by chance or not at all.

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The New Conversational Domain of Leadership

There is a prevailing conversational domain of leadership that has existed for years. It includes words like vision, strategy, value, culture, and accountability, terms that are familiar to most everyone. This conventional leadership model explains performance (e.g., value) as an effect of some cause (e.g., improving quality, reducing costs) and assigns that cause to some combination of the leader's physical and mental characteristics and attributes (e.g., decisive, opportunistic) as well as the external circumstances of the performance situation.22 This dominant worldview of leadership is deeply embedded in the mental maps of most individuals and organizations. This view is not wrong or ineffective. In fact, it is necessary. But, unlike the ontological orientation, it provides us only nominal access to our human ways of being and acting that limit our leadership effectiveness. It grants us limited action-focused access to create for ourselves what it is to be a leader and what it is to exercise leadership effectively as our natural self-expression.

For example, when an intern is dealing with a “coding” patient in the intensive care unit, knowing that he or she should be composed in that situation is very different from being composed. Providing excellent patient care in that moment depends on generating a different way of being than what is likely to be his or her default way of being (nervous, ruffled, frantic). The resident must discover for him- or herself—as a living, breathing experience—that he or she is not stuck with any particular way of being; rather, the resident can choose to be whatever way is required for him or her to be and function at his or her best at that moment. The resident's experience of having previously lived through stressful situations (likely outside the realm of patient care) gives him or her access to dealing with his or her lack of composure as a way of being, which means the resident can act with authentic composure in the face of trepidation.

As with medicine, there are terms and terminologies in the conversational domain of leadership that are intended to structure learning, access, and practice; as pointed out by Boje and colleagues,23 “what we create in language ‘uses us’ in that it provides a point of view (a context) within which we know reality and orient our actions.” This capacity of language to function as a lens (a context) through which we make meaning of and interact with the world is inevitable and powerful. It is inevitable because we are born into language. It is powerful because if we get the language right, it allows us to function more effectively as leaders. Thus, we want to create and master a conversational domain that provides us with the most power and effectiveness to observe, perform, communicate, and innovate.

When the new conversational domain of leadership is mastered, what is created in language generates a context that uses practitioners—physicians, teachers, researchers, administrators—such that they are left with new opportunity sets for being leaders who lead effectively and powerfully. This new language domain requires mastery of new terms and terminologies, which include expressions such as already-always-listening,4 the occurring world, the way you wound up being,4 clearing,11 terminal diagnoses, prescriptions for life, the 6As,17,24 our SO-SO future,17 and mental hard drives. 17 Table 1 gives brief definitions of these and other such terms. Scholars of language and leadership have chosen these terms because they help people discover, as a first-person lived experience, the ontological constraints that limit them from leading as their natural self-expression.

Each of us acquires, early on, an already-always-listening that filters and distorts virtually everything we encounter.4 It may occur for us as that ever-present voice in our head that we are often unaware of. One presumes that it is “just me” thinking something over with oneself, but once we discriminate this listening as involuntary and that we are on autopilot, it is more like a listening that is thinking for and controlling us. While we each have our own listenings, a very common already-always-listening is the one that says, “I'm not good enough the way I am.” I call such a self-assessment a terminal diagnosis because such judgments become lifelong limiting contexts that shape our approaches to life. As these diagnoses are for life, they are the already-present and always-present contexts that distort the way we occur for ourselves and the way life occurs for us. A terminal diagnosis becomes a chapter in our life stories through which life thereafter is listened to and dealt with. Although we are often unaware of this self-indictment, it becomes imprinted into our mental maps, often with lifelong unhealthy consequences.

Given that terminal diagnoses are part of being human, we invariably seek out some treatment or remedy to make them not terminal. The origin of the ontological constraint that can be called a prescription for life starts with a decision (a terminal diagnosis) about what we could never achieve or be. To cope with or palliate those situations where we might fail or not measure up, we tend to default to certain ways of being and acting that we learned early on. They are the best ways we know to compensate for our perceived inadequacies and insecurities that surface when we are stressed or threatened. This strategy is part of the way we wound up being (see Table 1). By the time we reach adolescence, we have each wound up with a set of ways of being and acting that seem to give us a certain measure of success.

The linguistic concept, the way you wound up being, is one that we can all relate to in our individual lives. Although many of our characteristic ways of being and acting are healthy and adaptive, some are not. Virtually all of us can experience as lived how a particular way we wound up being constrains us to a certain range of self-expression and leaves us confined to a limited set of possible ways of being and acting and to a certain fixed set of formulas for getting by.4 Thus, we must be willing to go beyond the way we wound up being, rather than simply tweaking it.

Our prescriptions for life are amongst the most common and limiting of the ways we wound up being. If persons decided as children that they were not good enough, their prescriptions for life may have been to overachieve (as I did) in an attempt to convince themselves and others that they do measure up. Six measures of looking good and measuring up in our culture—the so-called 6As: achievement, authority, attention, appearance, admiration, and affluence—are universal prescriptions for life17; they seem to give us a sense that we look good, measure up, and have status, inauthentic though they may be.

What gets in the way of our natural self-expression (as leaders) are the limiting ways we wound up being. For example, if one of our terminal diagnoses is that we are not liked enough, our prescription for life may be to be nice to everyone, to avoid conflict, or to be overly compromising. When it comes to having tough conversations or making a decision, such individuals often shirk their leadership responsibilities. Or, when confronted with a difficult budget problem, our usual way of being may be one of avoidance or making excuses or blaming. These ways of being and acting reflect how the budget challenge occurs for us—perhaps as not our fault or too daunting to take on or too risky to hold people accountable.

Terminal diagnoses constrain our being and actions when we are called on to provide leadership because they trigger prescriptions for life that become unhealthy default ways of being and acting. If, as a leader, my fixed way of being under duress is to avoid the issue, I am unlikely to be exercising effective leadership. If my range of possible leadership responses is limited, they will only be effective in situations that fit that range. Expanding the realm of possible leadership strategies will allow me to exercise competent leadership under a broader range of situations. In the act of distinguishing, I can let go of these constraints (unwarranted diagnoses) and, in so doing, make space for new ways of being and thinking that unleash more effective leadership. This clearing away of outdated worldviews and prescriptions for life is the ontological equivalent of cleaning out our desks.

To recap, language provides action-focused access to our ways of being and acting in dealing with any leadership challenge. The way we choose to speak to others and to ourselves about the challenges we are dealing with shapes and colors the way those challenges occur for us. For example, when we tell ourselves that the particular circumstances we are dealing with are “vexing,” such an assessment lives only in language. “Vexing” is an interpretation (a context) we add to the details of the situation. Of course, situations often do occur for us that can fairly be interpreted as vexing, but we must always remember that even then, they are vexing because we say they are.

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Will the “Real Me” Please Stand Up … and Lead?

Eighty-five years ago, Harvard physician and philosopher William James25 wrote:

I have often thought that the best way to define a man's character would be seek out the particular mental or moral attitude in which, when it came upon him, he felt himself most deeply and intensively active and alive. At such moments, there is a voice inside him which speaks and says: This is the real me.

James' words convey the notion of leading as one's natural self-expression. That term often relates to the expression of one's individuality, but, as it relates to leadership, it refers to that way of being and acting in dealing with any particular leadership challenge that is an intrinsic, unforced, and fitting response for the particular situation one is dealing with. More concisely, in a particular set of circumstances that call for leadership, only if one's way of being and acting is naturally self-expressed will that way of being and acting be inherent, instinctive, and optimally effectual—that is, natural for that leader in that leadership situation.

Most of us think that the way we are being and acting moment-to-moment is our natural self-expression. However, our natural self-expression is limited and distorted by our prescriptions for life that have become a part of the way we wound up being. As a result of these constraints, each of us gets left with characteristic personal ways of being and acting that allow us to succeed in some situations but which leave us, at best, getting by in others and, unfortunately, failing in yet others.4

When one is leading as one's natural self-expression, one tends to be more creative and generous and, at the same time, less stressed and judgmental. It is virtually impossible to be at one's personal best as a leader if one's way of being and acting is unnatural, strained, or awkward. One's natural self-expression as a leader can be understood as an “objectification” of the self, “an expression of inner spirit that externalizes and actualizes it,”26 a way of being-in-the-world that has been colloquially called flow, in the zone, in the groove, or at the top of one's game.

Self-expression can be natural (authentic) or unnatural (inauthentic). To some degree, all humans are inauthentic, a consequence of their socialization. Scarr27 stresses that

cultures set a range of opportunities for development; they define the limits of what is desirable, “normal” individual variation…. Cultures define the range and focus of personal variation that is acceptable and rewarded.

In the process of enculturation, the full range of possibilities for being becomes narrowed; the child's “clearing” (i.e., opportunity set) becomes restricted, an inevitable outcome of being human. Without at least some of the 6As, we are told by our parents and the media, we are not quite good enough and perhaps even a loser.

Young children are naturally self-expressed because they have not yet wound up being any particular way. They are free to be, unencumbered by any confining way of being. The context that shapes the way any set of circumstances occurs for them has not yet been created, so perception is not distorted by a listening that says, “I'm not smart enough” or “That's impossible.” Soon enough, however, the way you wound up being process starts to get hard-wired, as it does in all of us. Once children begin to talk to themselves—a capacity acquired as they learn to talk to their parents (others)—they begin interpreting their experiences and creating their own contexts, that is, their mental maps and assumptions about how life works. This phenomenon arises in learning to speak because contexts are constituted by way of language.

The point is, until we begin unshackling ourselves from those constraints, we have little access to ways of being and acting that lie outside the way we wound up being. It is the (limiting) ways we wound up being that hinder our natural self-expression in everything we are and do. They are like handcuffs. Becoming aware of these handcuffs creates the possibility of loosening the confining grasp they have on us. When leaders locate and reflect on examples of these ontological handcuffs in their own lives, the limitations they impose tend to relax.

Consider the possibility that leadership is not unlike hitting a baseball (see Box 2). Much as the batter does not know what pitch will be thrown his or her way, leaders, to use Heideggerian terminology,9 get “thrown” into unanticipated situations all the time. We get thrown under the bus, thrown a curve, and even thrown at. When the situations we are dealing with show up for us as doable—that is, we can say, “I can do this; I can deal with this”—we then are able to relax the tight hold that the handcuffs of our engrained assumptions and beliefs have on us; our way of being and our actions will be correlated with the way that the situations occur for us. When these changes take place, we become true leaders and exercise leadership effectively as our natural self-expression.5 Glass28 points out that “people are not free to choose the time, place, meanings, standards, and so on into which they have been thrown …, yet they are able to take up specific stances within that context and make of it what they may.”

Box 2

Box 2

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A New Model of Leadership Performance in Health Care

Most leadership approaches focus on altering the issues at hand, that is, modifying the content the leader is dealing with. Although this strategy should always be entertained, many of the issues we are dealing with today—reimbursement, duty hours, tight extramural funding—are conditions we must accept. To tackle them requires addressing context as well as content (as described in Table 2, which offers a brief analysis of the prevailing and the emerging models of leadership performance). Leadership invariably involves changing our occurring world, that is, the way the situation we are dealing with occurs for us. Mastery of the new conversational domain of leadership provides health care leaders with action-focused access to create for themselves—regardless of the leadership challenge they are dealing with—what it is to be a leader and what it is to exercise leadership effectively, such that their being and action becomes a context that uses those leaders.4

Table 2

Table 2

Mastery is key; competence, even proficiency, is insufficient, because only in mastery can we create a context that, in any leadership situation, has the power to use us—that is, to leave us being leaders and exercising leadership effectively as our natural self-expression. When any conversational domain is mastered, it provides access to what the conversation is actually dealing with (i.e., as a lived experience) as opposed to merely providing an understanding of what it is dealing with. All surgeons, for example, will corroborate that the occurring—the open belly, the injured child, the septic patient—shows up for them differently over time as they master the language domain. One chief surgical resident I worked with observed:

When I was a student and first laid eyes on an open belly, all I saw was a bunch of guts. It made no sense. I watched the surgeon cut and sew effortlessly and I thought, “I can't imagine ever being able to do that myself.” But with time, things somehow fell into place; I guess I started to master what it meant to be a surgeon and to perform technically sound operations. The specific anatomical relationships and approaches to the operation were always there, but previously I just didn't distinguish them.

Figure 1 depicts the elements of a new model of leadership performance in health care:

Figure 1

Figure 1

  • The source of the leader's performance, which is most fundamentally a product of the leader's actions (or inactions).
  • The source of the leader's action(s), which are always correlated with the way in which the circumstances the leader is dealing with occur for that leader; stated differently, this correlation is the source of action.
  • The way in which the circumstances each leader is dealing with occur is always colored and shaped by the context the leader brings to those circumstances; thus, it follows that when the occurring (i.e., whatever the leader is dealing with in the moment) is altered, the correlated action is altered. The target of access to action is the occurring itself.
  • Context powerfully colors and shapes the occurring; context, then, is the target of access to the occurring.
  • Language (i.e., the conversational domain that uses the leader) is the source of access to creating a new context and to shifting the occurring.

To summarize: Although performance is ultimately a product of action, altering the leader's context when dealing with a leadership challenge is critical. Because the ontological constraints that limit our natural self-expression are linguistically shaped and accessible, linguistic “unconcealment” is the means by which recontextualization occurs (see Box 3 for an example). Our hidden contexts determine what we see and what we do not see, what we pay attention to and what we ignore, what we take for granted, and what we attend to. If they can be brought to light, we can begin to see the process by which they were designed and the degree to which they control our lives. This “contextual enlightenment,” or distinction, provides us with ways of being and acting as leaders that were previously unavailable. Said otherwise, master leaders use language to recontextualize their leadership challenges so that their naturally correlated ways of being and acting result in exceptional leadership.

Box 3

Box 3

What is often challenging for those in health care who have or will have leadership accountabilities is practicably accessing (“getting a handle on”) what it is to be a leader and to lead in a way that goes beyond what they have read or been told and beyond some kneejerk way of reacting to a problem. Actually getting access to—in the sense of making use of, applying, or putting to work—the being and actions of leading can be unwieldy, even alien. Rather than just knowing about leadership (as one might know about the solar system), we want to leave people with access to being leaders and effectively exercising leadership as their natural self-expression. Accessing leadership, by analogy, would be like a surgeon accessing his or her hands in order to exercise his or her craft. Our hands, of course, are readily physically accessible—right there when we need them—but the idea is to be able to “get our hands” on leadership any time, in any situation, in order to be leaders and lead effectively as our natural self-expression.

These conversational domains (linguistic spheres), when learned, become contextual frameworks that use their practitioners to create the being and action that is necessary to be experts and to lead in their fields. For example, a physician might scan the list of inpatients he or she must “round on” in the hospital today. But that list is much more than black marks on a piece of paper that appear as letters, numbers, and words. Rather, the physician experiences the list in the context of unique human beings who happen to be afflicted with particular ailments: people who require certain interventions, have feelings, and are vulnerable. The checklist will be visually inputted into the brain as a sheet of paper with symbols on it, but it is interpreted cognitively inside a language context that includes thinking but also feelings, intentions, and planning.

All leaders want to perform at their personal best. This can only happen when one is leading as one's natural self-expression. When we try to be someone else or adopt other people's styles and mannerisms, it is always unnatural. Such forced leadership is much like trying to sign your name using your nondominant hand.

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Creating a Future That Is Not a Continuation of the Past

Leadership potential lives inside each of us, waiting to be unleashed and put to work in the world. Rather than adding more certificates, degrees, and titles to our leadership lapel, I argue that a more fundamental strategy involves revealing the ontological constraints inherent in the way we leaders wound up being that get in the way of leading as our natural self-expression. In mastering the conversational domain of leadership, a powerful framework, one grounded in authenticity and integrity, emerges that anchors one in being a leader and exercising successful leadership.3

Although we need a new science of leadership, this new science is unlikely to be, at least in the foreseeable future, a science solely of prediction and control. Accepting this will be counterintuitive and challenging for those of us who prefer cause-and-effect explanations to unconventional ones. Fortunately, the available literature on leadership theories and concepts has much to offer. When theories and concepts inform and complement the phenomenological experience, they both enlighten and guide.

Unlike medicine, where achieving expertise requires preparation, training, and time, many of the “as lived” experiences required for mastery of the new conversational domain of leadership (the mastery that allows one to exercise effective leadership) are already present, because they are part of every human being's life story. They only need to be revealed. This is what ontological inquiry does. When leaders expose their blind spots, filters, and other ontological constraints, the way in which any situation or person occurs (shows up) for them is less distorted by these blind spots, etc., and thus emerges as close as possible to the way it or she or he actually is. The possibility then exists for being a leader and exercising leadership as one's natural self-expression and with the greatest degree of awareness, commitment, integrity, and authenticity.3 The outcome, however, is much more consequential than just speaking a new vocabulary; it affords practitioners a certain authority because they have access to a form of leadership that others do not have. Health care enterprises whose leaders master this unique capacity will have a distinct advantage.

Like two dancers in a tango who are entangled as they embrace, leading as one's natural self-expression can be thought of as an entangoment. The leader is in a tango with the occurring(s)—the leader's being and actions always necessarily correlated with whatever leadership situations he or she is tangoing with, leading as his or her natural self-expression, at the top of his or her game. Tango master dancer and instructor Sharna Fabiano explains:

The tango is a metaphor for the way we relate to the world and to each other…. As we learn the “lead and follow” technique of the tango, it becomes possible to see miscommunications rather than errors, and to seek greater clarity within the nonverbal dance language rather than blaming our partner for taking the wrong step.29

John Sloan Dickey, Dartmouth's 12th president, told students in his 1946 convocation address, “The world's troubles are your troubles, and there is nothing wrong with the world that better human beings cannot fix.”30 Dickey's message is more urgent today than ever. The ontological leadership perspective equips us as leaders to tackle the troubles that face us because it gives us direct access to the fundamental barriers that lead us to avoid those troubles. Only by means of the conversational domain of leadership can we work together to tackle the world's troubling problems.5 Leadership in this sense is an exercise in language that changes the occurring, thereby allowing for the bringing forth of a future that is no longer a continuation of the past. So my message to all leaders and aspiring leaders is this: Only by means of the language of leadership can you and I cultivate and nurture ourselves and others, each and every day, to become the wiser, more enlightened, and more evolved human beings that we are intended to become. Only through language can we create and use that discerning wisdom to solve the world's problems prudently and compassionately and, in so doing, contribute to global transformation. We are the “languagers” of our future. Let us not pass on that opportunity to be homo sapiens, to be wise people. It is a calling that is both a responsibility and a privilege.

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The author thanks Werner Erhard, Joe DiMaggio, Michael Jensen, and Kari Granger for their helpful conversations and insights.

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Other disclosures:


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Ethical approval:

Not applicable.

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